JUST FOR KIDS PEDIATRICS, PLLC

Today’s Date:

Patient Name:

DOB:

Completed by:

Date:

Birth History:

Birth Hospital:

City:

Birth weight:

Discharge Weight:

Apgars:

Gestational age in weeks:

Delivery:

C-section Vaginal

Vacuum:

Yes No

Breech:

Yes No

Prenatal Labs: Mom’s age:

Mom’s blood type:

Rubella:

RPR:

GBS:

HepBsAg:

Maternal medications:

Pregnancy Complications:

Premature Rupture of membranes:

Yes No

Preterm Labor:

Yes No

Delivery Complications:

Fetal distress:

Did mother receive Tdap vaccine:

Yes No

NICU admit:

Yes No

Baby’s blood type:

Jaundice:

Yes No

Bilirubin Level:

Phototherapy:

Hearing screen:

Pass Fail

Cardiac Screen (CCHD):

Pass Fail

Newborn Screen #1 done:

Yes No

Hep B vaccine received:

Yes No

Drug Allergies:

Yes No

If yes, what reaction:

Drug:

Past Medical History for child:

ADD/ADHD:

Yes No

Developmental or behavioral problem:

Yes No

Allergies/Hayfever:

Yes No

If yes, please list:

Diabetes:

Yes No

Anemia:

Yes No

Difficulty swallowing:

Yes No

Anxiety disorder:

Yes No

Ear or Hearing problems:

Yes No

Asthma:

Yes No

Head injury/concussions:

Yes No

Autism:

Yes No

Headaches:

Yes No

Bedwetting:

Yes No

Heart murmur/heart problem:

Yes No

Bladder/kidney problem:

Yes No

Hospitalizations:

Yes No

Blood disease:

Yes No

Mental illness:

Yes No

Cancer:

Yes No

Muscle/joint/bone problems:

Yes No

Chicken pox:

Yes No

Seizures/epilepsy

Yes No

Chronic ear infections:

Yes No

Skin Problems:

Yes No

Congenital anomalies:

Yes No

Thyroid Problems:

Yes No

Constipation:

Yes No

Vision or Eye Problems:

Yes No

Depression:

Yes No

Other:

Surgeries and dates:

Family Medical History:

Allergy:

Yes No

If yes, Who?

Asthma:

Yes No

If yes, Who?

Anemia:

Yes No

If yes, Who?

Anxiety Disorder:

Yes No

If yes, Who?

Blood disease:

Yes No

If yes, Who?

Depressive disorder:

Yes No

If yes, Who?

Developmental disorder:

Yes No

If yes, Who?

Diabetes mellitus:

Yes No

If yes, Who?

Disease of liver:

Yes No

If yes, Who?

Disorder of Thyroid Gland:

Yes No

If yes, Who?

Seizure:

Yes No

If yes, Who?

Substance abuse:

Yes No

If yes, Who?

Mental disorder:

Yes No

If yes, Who?

Heart disease:

Yes No

If yes, Who?

Hypercholesterolemia:

Yes No

If yes, Who?

Hypertensive disorder:

Yes No

If yes, Who?

Immunodeficiency Disorder:

Yes No

If yes, Who?

Kidney disease:

Yes No

If yes, Who?

Cancer:

Yes No

If yes, Who and what type?

Migraine:

Yes No

If yes, Who?

Tuberculosis:

Yes No

If yes, Who?

Other:

Is there a history of heart disease in the family, before the age of 50 years?

Yes No

If yes, Who?

Are there irregular heart rhythms in the family (arrhythmias):

Yes No

If yes, Who?

Sudden death in the family?

Yes No

If yes, Who?

Enlarged heart (cardiomyopathy, HOCM) in the family:

Yes No

If yes, Who?

Does your child ever complain of chest pain, palpitation, shortness of breath, passing out, or nearly passing out?

Yes No

Social History:

Patient lives with:

Parents’ Marital Status:

Siblings and Ages:

School:

Grade:

Pets:

Yes No

Tobacco exposure:

Yes No

Guns:

Yes No

Pool exposure:

Yes No

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