Patient Medical History and Family Medical History

Child’s Name:

DOB:

Household:

Please list all those living in the child’s home.

Add child

What is the child’s living situation?

Lives with mother and father Lives with adoptive parents Joint custody Single custody Foster family

If one or both parents are not living in the home, how often does the child see the parent(s) not in the home?

Birth History:

Birth History unknown

Please select:

Vaginal C-Section

Please select:

Full Term Premature

If "premature", weeks completed:

Birth Weight:

Length:

Were there any prenatal or neonatal complications?

Yes No

Was a NICU stay required?

Yes No

If yes, please explain:

General History:

Do you consider your child to be in good health?

Yes No

If no, please explain:

Do you think your child’s development is:

On Target Delayed

If delayed, please explain:

Has your child ever been hospitalized or had surgery?

Yes No

If yes, please explain:

Is you child allergic to medications or foods

Yes No

If yes, please explain:

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Form Completed By:

Date:

Patient Medical History

Does your child have, or has your child ever had?

Chicken Pox

Yes No Unknown

When:

Frequent ear infections

Yes No Unknown

Explain:

Problems with ears or hearing

Yes No Unknown

Explain:

Nasal allergies

Yes No Unknown

Explain:

Problems with eyes or vision

Yes No Unknown

Explain:

Asthma, Bronchitis, bronchiolitis or pneumonia

Yes No Unknown

Explain:

Any heart problems or heart murmur

Yes No Unknown

Explain:

Anemia or bleeding problems

Yes No Unknown

Explain:

Blood transfusion

Yes No Unknown

Explain:

HIV

Yes No Unknown

Explain:

Organ transplant

Yes No Unknown

Explain:

Cancer

Yes No Unknown

Explain:

Genetic disorder

Yes No Unknown

Explain:

Frequent abdominal pain

Yes No Unknown

Explain:

Constipation requiring doctor visit

Yes No Unknown

Explain:

Recurrent urinary tract infection/problems

Yes No Unknown

Explain:

Kidney disease or urological malformation

Yes No Unknown

Explain:

Bed-wetting (after 5 years)

Yes No Unknown

Explain:

Sleeping problems, snoring

Yes No Unknown

Explain:

Recurring skin problems (acne, eczema)

Yes No Unknown

Explain:

Epilepsy or convulsions

Yes No Unknown

Explain:

Obesity

Yes No Unknown

Explain:

Diabetes

Yes No Unknown

Explain:

Thyroid or endocrine problems

Yes No Unknown

Explain:

High Blood pressure

Yes No Unknown

Explain:

High cholesterol

Yes No Unknown

Explain:

Serious injuries, fractures or concussions

Yes No Unknown

Explain:

Alcohol or drug use

Yes No Unknown

Explain:

ADHD, anxiety, mood problems or depression

Yes No Unknown

Explain:

Dental decay

Yes No Unknown

Explain:

Sexually transmitted infections

Yes No Unknown

Explain:

(For girls) had first period

Yes No Unknown

When:

Family history

Family history Unknown

Have the child’s parents, grandparents or siblings have/had any of the following?

Childhood hearing loss

Yes No Unknown

Explain:

Nasal allergies

Yes No Unknown

Explain:

Asthma

Yes No Unknown

Explain:

Tuberculosis

Yes No Unknown

Explain:

Heart disease (before 55 yrs.)

Yes No Unknown

Explain:

High Cholesterol

Yes No Unknown

Explain:

Anemia

Yes No Unknown

Explain:

Bleeding disorder

Yes No Unknown

Explain:

Dental decay

Yes No Unknown

Explain:

Cancer (before 55 yrs.)

Yes No Unknown

Explain:

Liver disease

Yes No Unknown

Explain:

Kidney disease

Yes No Unknown

Explain:

Diabetes

Yes No Unknown

Explain:

Bed-wetting (after 5yrs)

Yes No Unknown

Explain:

Obesity

Yes No Unknown

Explain:

Epilepsy or convulsions

Yes No Unknown

Explain:

Alcohol abuse

Yes No Unknown

Explain:

Drug abuse

Yes No Unknown

Explain:

Mental illness/Depression/anxiety

Yes No Unknown

Explain:

Immune problems

Yes No Unknown

Explain:

HIV/AIDS

Yes No Unknown

Explain:

Tobacco Use

Yes No Unknown

Explain:

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