Child Health History Form

PATIENT'S Full Legal Name

Date of Birth

Today's Date

Demographics

PATIENT impaired

Yes No Impairment

If yes, please select?

Hearing

Vision

Is PARENT impaired

Yes No Impairment

If yes, please select?

Hearing

Vision

If yes, please select?

Mom

Dad

Declined to Specify

Preferred Language

Pregnancy and Birth

Birth Weight

Birth Length

Mother’s age @ time of baby’s birth

Infant’s gestational age

Full Term

Post-term

Pre-term

No. of weeks

Blood Type of Mother

Infants Blood type (if known)

Apgar Scores (if known)

Type of Delivery

Vaginal C-section

If C-section, reason

Group B Strep Status of Mother

Initial feeding of baby

Breast Formula Both

Name of Obstetrician/City/State

If yes, explain

Were there any medical problems during the pregnancy? (i.e., diabetes, infections, high blood pressure, breech presentation, preterm labor)?

Yes No

If yes, explain

Were there any problems during labor?

Yes No

If yes, explain

Were there any problems during the nursery stay? (i.e., jaundice, feeding difficulties, infections, breathing problems, prematurity)?

Yes No

If yes, explain

Hospitalizations or Serious Illnesses

List any serious and/or unusual illnesses which your child has experienced and the corresponding date(s):

Add Additional Hospitalizations

Allergies

List allergies, including allergic reactions to medications:

Family History

provide all boxes where the child or a member of the child's family (parents, siblings, grandparents, aunt, uncles) have had the following illnesses or problems:

Frequent ear infections

Frequent colds/sore throats

Croup

Cystic Fibrosis

Wheezing/Asthma

Pneumonia

Eye problems

Dental problems

Hearing problems

Hay fever

Eczema/Skin problems

Anemia/Blood problems

Diabetes

Kidney/Bladder problems or infections

Seizures/Convulsions

Early heart disease (age 50 or less)

High blood pressure

High Cholesterol

Lung disease/Tuberculosis

Sexually transmitted diseases

Alcohol/Drug abuse

Emotional disorders/Suicide attempts

Cancer

Unexplained childhood deaths

Other illnesses: Please list

If Other, Please specify

General Health

Add Additional Member

Have any of the child's brothers or sisters died?

Yes No

If yes, explain

Health & Safety Issues

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.

Signature

Date

Your information will be encrypted.