Health History

Name of Patient:

Sex:

Male Female

Date of Birth:

Name of person completing form:

Relationship:

Please list all People in your household

Fathers Name:

Date of Birth:

Relationship to Patient:

Mothers Name:

Date of Birth:

Relationship to Patient:

Add Other Person

Have there recently been any major changes or stresses in your child’s life?

Yes No

If yes, please explain:

Does the child regularly go to a baby-sitter, pre-school, or day care?

Yes No

Is your child exposed to cigarette smoke?

Yes No

Is there a gun or weapon in the home?

Yes No Locked

Is there a pool on your property?

Yes No

Are there any pets in the home?

Yes No

Does your child use a car seat?

Yes No

Does your child have any current legal involvement?

Yes No

When was your child’s last primary care visit?

Name of physician or practice:

Has your child been seen by a dentist?

Yes No

Last Visit (Approx):

Birth History

Birth Weight:

Length:

Place:

During Pregnancy did the mother:

Have any Medical Problems:

Yes No

If yes, please explain:

Smoke or Drink:

Yes No

If yes, please explain:

Use any Medications:

Yes No

If yes, please explain:

Use Alcohol or Drugs:

Yes No

If yes, please explain:

Have Problems with Labor/Delivery:

Yes No

If yes, please explain:

Development

Do you have any concerns about your child’s development?

Yes No

Do you have any concerns with the following?

Behavior

Sleeping Habits

Eating Habits

Bathroom Habits

School

Other

If you checked Other, please specify:

Regarding Immunization/Vaccines, is your child:

Up-to-Date Delayed Have Concerns with Vaccines Unsure

Family History

Have any of the Child’s brothers and sisters died? If Yes, please give age and cause:

Yes No

Have any of the child’s blood relatives had the following diseases:

Heart Disease:

Yes No

If yes, please list family member:

Tuberculosis:

Yes No

If yes, please list family member:

High Blood Pressure:

Yes No

If yes, please list family member:

Kidney Disease:

Yes No

If yes, please list family member:Short text field

Allergies/Asthma:

Yes No

If yes, please list family member:

Cancer:

Yes No

If yes, please list family member:

Diabetes:

Yes No

If yes, please list family member:

Mental/Emotional Problems:

Yes No

If yes, please list family member:

Blood Disorders:

Yes No

If yes, please list family member:

Seizures:

Yes No

If yes, please list family member:

Drug/Alcohol Problems:

Yes No

If yes, please list family member:

High Cholesterol:

Yes No

If yes, please list family member:

Stroke:

Yes No

If yes, please list family member:

Autoimmune Disease:

Yes No

If yes, please list family member:

Anxiety/Depression

Yes No

If yes, please list family member:

Other:

Yes No

If yes, please list family member:

Other:

Yes No

If yes, please list family member:

Past Medical History

Is your child’s general health:

Good Fair Poor

Does the child have any allergies?

Yes No

Is the child taking any medications?

Yes No

Please list any hospitalizations, operations, serious illnesses, or accidents:

Has your child had any problems with the following?

Eyes/Vision:

Yes No

If yes, please explain:

Skin:

Yes No

If yes, please explain:

Feet:

Yes No

If yes, please explain:

Lungs:

Yes No

If yes, please explain:

Digestion/Nutrition:

Yes No

If yes, please explain:

Teeth:

Yes No

If yes, please explain:

Ears/Hearing:

Yes No

If yes, please explain:

Heart:

Yes No

If yes, please explain:

Urine/Kidney:

Yes No

If yes, please explain:

Seizures

Yes No

If yes, please explain:

Infections:

Yes No

If yes, please explain:

Joints:

Yes No

If yes, please explain:

Is your child currently seeing any specialists: (Example: pulmonologist, behavioral health, nutritionist, etc…)

To be Completed by Teenage Patients

Do you Use Tobacco:

Yes No

Drink Beer or Alcohol:

Yes No

Use any kind of Drugs:

Yes No

Do you have concerns about any of the following?

Yes No

Safety Issues?

Yes No

Substance use in family?

Yes No

Sexually Transmitted Diseases?

Yes No

Family Planning?

Yes No

For Women

How old were you when you had your first period?

Are you sexually active?

Yes No

Are you using any form of birth control?

Yes No

Have you ever been pregnant?

Yes No

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