Pediatric Health Information

Patient's Name

Date of Birth

A. Health Care Status

1. Where has your child gone for check ups until now?

2. What is the date of your child's last checkup?

3. What is the date of your child's last dental checkup?

4. Is your child under treatment now for an illness or medical condition?

Yes No

If yes, for what?

With whom?

5. Has your child had allergic reactions to any medications

Yes No

6. Has your child had reactions to any immunizations?

Yes No

If yes, Please list

7. Any hospitalizations other than birth?

Yes No

If yes, please list

8. Does your child take any medications regularly, including over the counter medications such as Tylenol or vitamins?

Yes No

If yes, please List

B. Pregnancy and Birth

1. Mothers age at birth of this child

2. Did mother have any illnesses during this pregnancy

Yes No

3. Did Mother use any medications other than vitamins?

Yes No

4. Was the baby born on time?

Yes No

5. What was the baby's birth weight?

6. Did the baby have any trouble starting to breath?

Yes No

7. Did the baby ave any trouble in the hospital? (Jaundice, infections , other?)

Yes No

If yes what kind?

C. Family History

1. Are the child's parents in good health?

Yes No

If other, please specify

3. List general health , age and sex of brothers and sisters

4. Have any of your children died?

Yes No

D. Feeding and Nutrition

1. Is your child's appetite usually good?

Yes No

2. Is it good now?

Yes No

3. Was there severe colic or any unusual feeding problems during the first 3 months of life?

Yes No

4. Do any foods disagree with your child?

Yes No

5. Is / was your child

Breast

Bottle Fed

Both

6. If still on formula which one do you use?

7. Does your child take vitamins?

Yes No

E. Review of Systems

1. Has your child had frequent ear infections?

Yes No

2. Has your child had any eye or vision problems?

Yes No

3. Has your child had any problems with teeth?

Yes No

4. Does your child have frequent colds or sore throats?

Yes No

5. Is there asthma, pneumonia or a recurrent cough?

Yes No

6. DOes your child have a heart murmur or any heart problems?

Yes No

7. Any problems with urination?

Yes No

8. Any problems with diarrhea or constipation?

Yes No

9. Have there been any convulsions or other problems with the nervous system?

Yes No

10. Any eczema, hives or other skin conditions?

Yes No

11. Has your child ever been anemic?

Yes No

12. Please list any other medical problems

F. Development / Behavior

1. At what age did your child sit alone?

2. At what age did your child walk alone?

3. Did your child say any words by the time he/she was 1 1/2 years old?

Yes No

4. How does your child compare to other children of his or her age?

5. Does your child have trouble sleeping?

Yes No

6. What grade is your child in?

7. Does your child get along with other children?

Yes No

if Other Please specifiy

G. Safety / Environment

1. Do you live in a

Private house

Apartment

Mobile home

Other?

2. Do you know the hottest temp of the water in your pipes?

Yes No

3. Is there a working smoke alarm on each floor where you live?

Yes No

4. Does your child always use a seat belt / car seat in a car?

Yes No

5. Do you forbid smoking in your house?

Yes No

6. Is your home regularly inspected for health hazards such as peeling paint, insects, rats or mice?

Yes No

7. Does your child wear a helmet when riding a bike?

Yes No

8. Do you have any firearms in the home?

Yes No

9. Have any of the child's caregivers been trained in CPR?

Yes No

10. Do you have the Poison control number?

Yes No

If yes, Please indicate

11. Kids under 10 never cross streets alone?

Yes No

12. Kids are always supervised in or near water?

Yes No

13. Are children protected against falls from windows, stairs, furniture and play ground equipment?

Yes No

14. Household cleaners, medicines and vitamins are stored out of young kids reach?

Yes No

15. Our home has emergency numbers near telephones and first aid supplies

Yes No

H. Immunization

Do you have a record of Immunizations?

Yes No

If yes, please give immunization record to nurse with this form

List any other questions for the doctor

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Date

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Physicians Signature

Date

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