Health History Over 1 Year

Child's name

Date of birth

Parent/Guardian's name

Date of birth

Relationship to child

Today's Date

Pregnancy/Neonatal Period

Where was your child born?

Was your child premature?

No Yes Unknown

Born at how many weeks?

Birth weight

Birth length

Other problems in the newborn period:

Infancy/Childhood/Adolescence

Has your child ever been treated or diagnosed with the following:

Asthma or reactive airway disease

No Yes

Please explain:

Wheezing or bronchiolitis

No Yes

Please explain:

Seasonal allergies

No Yes

Please explain:

Eczema

No Yes

Please explain:

Food allergy

No Yes

Please explain:

Recurrent ear infections

No Yes

Please explain:

Pneumonia

No Yes

Please explain:

Urinary tract infections

No Yes

Please explain

Seizures

No Yes

Please explain

Anemia

No Yes

Please explain

Concussion

No Yes

Please explain

Depression/anxiety

No Yes

Please explain

Heart murmur

No Yes

Please explain

Constipation

No Yes

Please explain

Chicken pox

No Yes

Please explain

Attention Deficit Hyperactivity Disorder

No Yes

Please explain

Other chronic medical conditions:

Has your child ever been hopitalized?

No Yes

If yes, please explain:

Please list any specialist your child has seen, dates and reason:

Medications

Does your child have any allergies to any medications or vaccines?

No Yes

If yes, please explain:

Please list current medications your child is taking with dose:

Development/Nutrition

Did/does your child have delayed development?

No Yes

If yes, please explain:

How does this child compare to other his or her age?

What grade is your child in?

Does he/she get along with other children?

No Yes

Do any foods disagree with your her/him?

No Yes

If yes, which ones?

Does your child get fluoride?

No Yes

How many hours per day does your child spend watching TV, playing video games, surfing the internet and/or social media?

What hobbies/extracurricular activities does your child participate in?

Social History

Who lives in the child's household?

Mother

Father

Sibling(s)

Grandparent(s)

Other

If other, who?

Number of siblings:

Sibling(s)

Brother

Sister

Step-brother

Step-sister

Child's parents are:

Married

Unmarried

Divorced

Other

Mother's occupation:

Father's occupation:

Childcare:

Parents

Relatives

Daycare

Nanny/babsitter

Do any household members smoke?

No Yes

Is there a gun in the home?

No Yes

If yes, is it locked and separate from the ammunition?

No Yes

Family History

Do any family members have any of the following conditions? This includes parents, siblings, and grandparents of the patient.

Asthma

No Yes

Asthma

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Allergies

No Yes

Allergies

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Anemia

No Yes

Anemia

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Blood disorder

No Yes

Blood disorder

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Cancer

No Yes

Cancer

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

High cholesterol

No Yes

High cholesterol

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

High blood pressure

No Yes

High blood pressure

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Heart attack/disease

No Yes

Heart attack/disease

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Diabetes

No Yes

Diabetes

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Thyroid disease

No Yes

Thyroid disease

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Seizures

No Yes

Seizures

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Migraines

No Yes

Migraines

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Autism

No Yes

Autism

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Anxiety

No Yes

Anxiety

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Depression

No Yes

Depression

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Alcoholism

No Yes

Alcoholism

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

ADD/ADHD

No Yes

ADD/ADHD

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Please explain:

Other issue not listed?

No Yes

Other issue not listed

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

If yes, please explain:

Review of Symptoms

Other issue not listed:

Email address