Medical History Form

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Patient Name

DOB

Parent/Guardian Signature

Date

Present Health Concerns

MEDICATIONS
Please list all prescription and non-prescription medications, vitamins, home remedies, birth control, herbs etc.

Add Medications

ALLERGIES
List all reactions to medicines, foods, and other agents.

Add Allergies

PERSONAL MEDICAL HISTORY

Please Specify

HOSPITALIZATONS: Please list all prior hospitalizations and dates

Add Hospitalizations

IMMUNIZATIONS:

COMMUNICABLE DISEASES:

Has the patient ever had any of the following communicable disease(s)?

Chickenpox

Measles

Mumps

Rubella

Meningitis

Tuberculosis (TB)

PREGNANCY & BIRTH:

Is the patient yours by

Birth Adoption Stepchild Other

If other, Please specify

Were there any medical problems during pregnancy?

Yes No

If yes,please explain

Were there are problems during labor and delivery?

Yes No

If yes,please explain

Were there any problems such as needing oxygen, trouble breathing, jaundice (yellowness), etc. after the patient’s birth?

Yes No

If yes,please explain

Where was the patient born?

Method of Delivery

Vaginal Caesarean

Birth Weight

Was your child born prematurely?

Yes No

If yes, how early?

For Male Patients Only: Is your child circumcised?

Yes No

SLEEP

How many hours a night does the patient sleep?

How many naps does the patient take per day and length of naps?

If yes, please explain

Does the patient have any sleep problems?

Yes No

NUTRITION & FEEDING

Type of feeding when the patient was a newborn

Breastfed Formula

If breastfed, for how long?

Has the patient had any feeding/dietary problems or restrictions?

Yes No

If yes, please explain

Has the patient seen a dentist?

Yes No

If yes, date of last visit

What is the water source at the house?

City Well

DEVELOPMENT

At what age did the patient

Sit Alone Walk Alone Say Words Toilet Train (Daytime)

Were there any concerns about growth or progress made in such areas as rolling over, walking, riding a tricycle, dressing themselves, or feeding themselves?

Yes No

If yes, please explain

Are there any area of concerns about language or speech development?

Yes No

If yes, please explain

When the patient is in the car, do they use?

Infant Seat Booster Seat Seatbelt Only

Does the patient wear a helmet while riding a bike?

Yes No

Do you have concerns about the patient’s behavior at home or in groups with other children?

Yes No

If yes, please explain

For Female Patients Only: Age at first menstrual period

Yes No

SOCIAL HISTORY

Are the patient’s parents

Married Never Married Separated Divorced

If divorced, for how long?

Mother’s Employer

Mother’s Occupation

Father’s Employer

Father’s Occupation

Do any household members smoke?

Yes No

Is violence in the home a concern?

Yes No

Are there guns in the home?

Yes No

Would you like to speak with the physician regarding the patient’s

Alcohol Use Tobacco Use Secualy Activity Aggressive Behavior

How many hours per day does the patient spend with the following:

Watching TV On the Computer/iPad Playing Video Games

Do you have any concerns about lead exposure due to having an old home, or because of plumbing, and peeling paint?

Yes No

Do you have smoke detectors in your home?

Yes No

Who lives at home with the patient?

Name

Age

Relationship

Highest Level of Education

SCHOOL HISTORY

Did/Does the patient attend school/preschool?

Yes No

Current grade in school?

Do you have concerns with how the patient is doing in school?

Yes No

Any concerns about relationships with teachers or other students?

Yes No

If more than 4 years old: does your child have a best friend?

Yes No

Does your child play any sports?

Yes No

How many times a week?

How Long (Minutes)

FAMILY HISTORY

Other Family Members Information: (please write in)

REVIEW OF SYSTEMS:

Please indicate with a check (√) any current problems your child has on the list below.

CARDIOVASCULAR

Chest pain/discomfort

Leg pain with exercise

Palpitations

RESPIRATORY

Cough/wheeze

Difficulty breathing

GASTROINTESTINAL

Abdominal pain

Blood in bowel movement

Nausea/vomiting/diarrhea

CHEST (BREAST)

Breast lump/discharge

MUSCULO-SKELETAL

Muscle/joint pain

SKIN

Rash or mole change(s)

PSYCHIATRIC

Anxiety/stress

Problems with sleep

Depression

Other

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Medical History Form

IMMUNIZATIONS:

COMMUNICABLE DISEASES:

PREGNANCY & BIRTH:

SLEEP

NUTRITION & FEEDING

DEVELOPMENT

SOCIAL HISTORY

FAMILY HISTORY

REVIEW OF SYSTEMS:

Phoenix Pediatrics