Health History

Child's Name

Date of Birth

Parent/Guardian's Name

Date of Birth

Relationship to child

Today's Date

Pregnancy and Birth

Maternal Exposures:

Medication?

No Yes

If yes, please explain

Drugs or alcohol?

No Yes

If yes, please explain

Tobacco?

No Yes

If yes, please explain

Birth problems for patient:

Jaundice?

No Yes

If yes, please explain

Infection?

No Yes

If yes, please explain

Breathing?

No Yes

If yes, please explain

Low blood sugar?

No Yes

If yes, please explain

Oxygen use?

No Yes

If yes, please explain

NICU stay?

No Yes

If yes, please explain

Was your child born premature?

No Yes

How many weeks?

Delivery:

Vaginal

C-section

Breech

Forceps

Where was your child born (please inclue hospital and city)?

Please explain

Birth weight

Birth length

Head circumference

Other problems in the newborn period

Past Medical History of Your Infant

Any medications taken regularly:

No Yes

If yes, which ones?

Any allergic reactions to medications?

No Yes

If yes, which ones?

Any allergic reactions to immunizations?

No Yes

If yes, which ones?

Any hospitalizations other than for birth?

No Yes

If yes, for what?

Other history?

No Yes

If yes, please explain

Safety/Environment

Is your water heater set to 120 degrees?

No Yes

Is there a working smoke alarm on each floor in the house?

No Yes

Does your child always use a car seat in the back seat when riding in the car?

No Yes

Do you place your baby to sleep on his/her back?

No Yes

Do you have help or support easily available?

No Yes

Any stresses in the family?

No Yes

If yes, please describe:

Where does the baby sleep?

Parent's room

Nursery

Sibling's room

Other

Feeding and Nutrition

Any unusual feeding problems?

No Yes

If yes, please describe

Type of feeding:

Breast

Formula

If breastfeeding, how long do you plan to continue?

If on formula, which one?

Does he/she take vitamins?

No Yes

If yes, which one(s)?

Review of symptoms

Any eye problems?

No Yes

Difficult or noisy breathing?

No Yes

Heart murmur or heart problem?

No Yes

Problem with stools (diarrhea or constipation)?

No Yes

Is he/she irritable or colicky?

No Yes

Any skin conditions?

No Yes

Problem with vomiting or excessive spit up?

No Yes

Please list any other medical problems or explain above problems:

Social history

Who lives in the child's household?

Mother

Father

Sibling(s)

Grandparent(s)

Other

Sibling(s)

Brother

Sister

Step-bother

Step-sister

Child's parents are:

Married

Unmarried

Divorced

Other

Mother's occupation:

Father's occupation:

Childcare:

Parents

Relatives

Daycare

Nanny/babysitter

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

Option 9

Please explain

Anxiety

No Yes

Anxiety

Mother

Father

Brother

Sister

Paternal Grandfather

Paternal Grandmother

Maternal Grandfather

Maternal Grandmother

Option 9

Please explain

Depression

No Yes

Depression

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

Alcoholism

No Yes

Alcoholism

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

Please explain