Pediatric Patient History Form

Social History

Parents:

Married Divorced Separated Single

Siblings - please list:

How many people live in your home?

Adults

Children

Is your child currently enrolled in daycare or school?

Yes No

Does your child participate in regular exercise?

Yes No

Please explain:

Does your child drink caffeine?

Yes No

Any smokers at home?

Yes No

Are there smoke detectors at home?

Yes No

Carbon Monoxide detectors?

Yes No

Any pets at home?

Yes No

If yes, please explain:

Are guns kept in your home?

Yes No

Do all family members use seat belts/care safety sets?

Yes No

Do all family members use helmets when biking?

Yes No

Any issues we should be aware of?

Yes No

Please List:

Medical History

Hospitalizations?

None Yes

If yes, please list:

Surgeries?

None Yes

If yes, please list:

Has your child had Hepatitis B vaccine?

Yes No

Has your child had Chicken Pox?

Yes No

If yes, when?

Has your child had Chicken Pox vaccine?

Yes No

Any Chronic Illnesses?

Yes None

If yes, please list them:

Has your child seen a sub-specialist?

Yes No

If yes, when:

Any developmental concerns or learning problems?

Yes None

If yes, please list:

Any behavioral problems or eating disorders?

Yes No

If yes, please list:

Any regular medications (over the counter or prescription or daily vitamin)? Include dose and frequency:

Any medical issues we should be aware of?

Yes No

Family Medical History

Year of birth (if known)

Child’s Father

Child’s Mother

Sibling

Maternal Grandparents

Paternal Grandparents

Sibling

Year of death (if known)

Child’s Father

Child’s Mother

Sibling

Maternal Grandparents

Paternal Grandparents

Sibling

Cause of death (if known)

Child’s Father

Child’s Mother

Sibling

Maternal Grandparents

Paternal Grandparents

Sibling

Heart Disease

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

High Blood Pressure

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Stroke

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

High Cholesterol

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Anemia

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Diabetes

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Please specify if onset as adult or child:

Asthma

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Tuberculosis

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Cystic Fribrosis

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Alcohol Abuse

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Drug Abuse

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Mental Problems

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Social Problems

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Psychiatric Problems

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Cancer (type)

Child's Father

Maternal Grandparents

Child's Mother

Paternal Grandparents

Sibling

Kidney Disease

Child's Father

Paternal Grandparents

Child's Mother

Maternal Grandparents

Sibling

Kidney Disease

Child's Father

Paternal Grandparents

Child's Mother

Maternal Grandparents

Sibling

Seizures

Child's Father

Paternal Grandparents

Child's Mother

Maternal Grandparents

Sibling

Congenital Birth Defects

Child's Father

Paternal Grandparents

Child's Mother

Maternal Grandparents

Sibling

Eating Disorders

Child's Father

Paternal Grandparents

Child's Mother

Maternal Grandparents

Sibling

Add Another

Communication Needs

Language if other than English:

Child

Parent(s)

Any special communication needs?

Yes No

If yes, explain:

Patient Education Assessment

Would you prefer patient education be provided to you or your child by:

Demonstration Written Material Other

If other, please explain:

Patient Rights

Is there anything we need to know about your religion or culture in order to care for your child?

Yes No

If Yes, please explain:

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

Parent Initials:

Date:

Medical Provider's Initials:

Date:

Your information will be encrypted.