Ennis Pediatrics - Patient Health History

PATIENT MEDICAL HISTORY

Patient Name

Date of Birth

BIRTH HISTORY

Complications During Pregnancy? If Yes, Please Specify:

Delivery Type

Vaginal Caesarian

If Caesarian, Why?

Gestational Age

Birth Weight

Birth Length

Hearing Screening

Passed Failed Not Done

TREATMENT HISTORY

Hospitalization (Dates and Reason)

Surgeries (Dates and Reason)

Specialists Seen

Medications

CHRONIC MEDICAL PROBLEMS

Allergies

Seasonal, Medication, Food

Developmental Delay

Please Specify

Other

Please Specify

FAMILY HISTORY

Check all that apply and list family members with medical condition

Diabetes

Family Member(s)

Seizures

Family Member(s)

Asthma

Family Member(s)

High Cholesterol

Family Member(s)

Anemia

Family Member(s)

Heart Disease

Family Member(s)

High Blood Pressure

Family Member(s)

Cancer

Family Member(s)

Eczema

Family Member(s)

Allergies (seasonal, medications, food)

Family Member(s)

Bleeding Disorder

Family Member(s)

Liver Disease

Family Member(s)

Kidney Disease

Family Member(s)

Crohn’s Disease, Irritable Bowel Disease

Family Member(s)

Mental Illness (Depression, Anxiety, Bipolar Disorder, Schizophrenia)

Family Member(s)

Other (please specify)

Family Member(s)