FAMILY AND MEDICAL HISTORY FORM

Please correct the errors described below.

PART 1: CHILD’S GENERAL INFORMATION

PARENT / PRIMARY CAREGIVER INFORMATION:

EMERGENCY CONTACT INFORMATION (other than parent/primary caregiver):

CURRENT SCHOOL INFORMATION:

OTHER PERSONS LIVING IN THE CHILD’S HOUSEHOLD:

PART 2: PREGNANCY AND BIRTH HISTORY

PRENATAL HISTORY:

CHILD’S BIRTH HISTORY:

PART 3: MEDICAL HISTORY OF CHILD

DIAGNOSTIC PROCEDURES COMPLETED BY: List specialist name, clinic, and procedure performed.

PRESENT HEALTH STATUS:

PART 4: NUTRITIONAL HISTORY

Describe a typical:

Rate the stress level affected by feeding times by the caregiver and individual:

PART 5: DENTAL HISTORY

Does the individual:

PART 6: DEVELOPMENTAL HISTORY AND MILESTONES

Indicate the age that your child first did each of the following INDEPENDENTLY. Also indicate whether your child performed this action EARLY, ON TIME, or LATE. If you can not recall a specific age, please mark whether you believe your child accomplished the milestone early, on time or late.

Has your child had problems with any of the following (beyond expected for child’s age):

PART 7: FAMILY MEDICAL HISTORY

PART 8: COMMUNICATION HISTORY

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