PEDIATRIC HEALTH HISTORY FORM

Date

PATIENT’S NAME:

DATE OF BIRTH:

AGE:

MOTHER’S NAME:

DATE OF BIRTH:

OCCUPATION:

FATHER’S NAME:

DATE OF BIRTH:

OCCUPATION:

PATIENT’S PREVIOUS DOCTOR:

PRESENT HEALTH CONCERNS:

Add medicine/vitamins

Add herbs/home remedies

Add allergies/reactions

1. PREGNANCY & BIRTH

Is this child yours by:

Birth Adoption Stepchild Foster Other

If Other, please specify:

Please indicate any medical problems during pregnancy:

None

Delivered by:

Vaginal Birth Caesarian

If caesarian, why?

Birth weight:

Birth length:

Please indicate any medical problems during the baby’s newborn period:

None

If premature how early?

2. NUTRITION & FEEDING

Was your child breastfed?

Yes No

If so, how long?

Has your child had any unusual feeding/dietary problems?

Yes No

If yes, please specify:

Milk intake what type:

Cow milk

Soymilk

Other

If cow milk is selected, please select:

Non fat1%fat

2% Fat

Whole milk

If other, please specify:

Average ounces per day (Note 8 ounces are in 1 cup):

3. SLEEP

Hours per night:

Naps (number & length):

Any sleep problems?

4. DEVELOPMENT

At what age did your child sit alone:

Walk alone:

Toilet train:

Say words:

Girls only: Age of first menstrual period:

5. DENTAL HISTORY

Has your child seen a dentist?

Yes No

If so, how often?

Date of last visit:

6. IMMUNIZATION

Please bring your child’s immunization record to all appointment

Refusal to vaccinate:

No Yes

Vaccine preference, explain:

Date of last TB test:

7. EXPOSURE/HABBITS

Any concerns about lead exposure? (Old home/pluming/peeling paint)

Yes No

Do any household members smoke?

Yes No

T.V. hours per day:

Computer per day:

Video Games hours per day:

8. PAST MEDICAL HISTORY

Please describe any major medical problems and their dates:

Add medical problem

Add hospitalization(s):

Has your child ever been treated for or diagnosed with:

Broken bones or severe sprains

If yes, please explain:

Seizures

If yes, please explain:

Asthma or reactive airway disease

If yes, please explain:

Anemia

If yes, please explain:

Wheezing or bronchiolitis

If yes, please explain:

Genetic syndrome

If yes, please explain:

Seasonal allergies or eczema

If yes, please explain:

Depression/anxiety

If yes, please explain:

Food allergies

If yes, please explain:

Pneumonia

If yes, please explain:

Recurrent ear infection

If yes, please explain:

Urinary infection

If yes, please explain:

Mental retardation or learning disability

If yes, please explain:

Other

If other, please specify:

Please list specialist your child is currently seeing:

Add specialist

9. FAMILY HISTORY

Do any family members have any of the following conditions?

Asthma

Mother

Father

Sibling

Grandparent

Anemia

Mother

Father

Sibling

Grandparent

Blood disorder

Mother

Father

Sibling

Grandparent

Cancer

Mother

Father

Sibling

Grandparent

Heart attack/disease

Mother

Father

Sibling

Grandparent

High cholesterol

Mother

Father

Sibling

Grandparent

High blood pressure

Mother

Father

Sibling

Grandparent

Stroke

Mother

Father

Sibling

Grandparent

Diabetes

Mother

Father

Sibling

Grandparent

Thyroid disease

Mother

Father

Sibling

Grandparent

Kidney disease

Mother

Father

Sibling

Grandparent

Seizures

Mother

Father

Sibling

Grandparent

Migraines

Mother

Father

Sibling

Grandparent

Depression/anxiety

Mother

Father

Sibling

Grandparent

Alcoholism

Mother

Father

Sibling

Grandparent

ADD/ADHD

Mother

Father

Sibling

Grandparent

Please explain all positives:

10. SOCIAL HISTORY

Who lives in the household with your child?

Mom

Dad

Siblings

Grandparents

Other

If "siblings" is selected, how many?

If other, please specify:

Child’s parents are:

Married Unmarried Divorced Other

If other, please specify:

Childcare:

Parent

Relatives

Daycare

Babysitter/nanny

Does your child attend School?

No Yes

Grade:

Any concerns about peer or teacher relationships?

Yes No

If yes, please explain:

Sports/exercise:

Type:

How often?

How long?

11. REVIEW OF ORGAN SYSTEM (Please check all symptoms that apply)

Neurological

Headaches

Weakness

Clumsiness

Muscular/Skeletal

Muscle pain

Joint pain

Blood/Lymph

Unexplained lumps

Easy bruising

Easy bleeding

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name:

DOB:

Relationship:

Date:

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