Goodman Pediatrics

Child's Name

Today's Date

Date of Birth

Pharmacy

Mother's Name

Mother's DOB

Mother's Address

Mother's Phone

Mother's Occupation/Employer

Father's Name

Father's DOB

Father's Address

Father's Phone

Father's Occupation/Employer

Guardian

Emergency Contact

List all members of child's primary household

Custody arrangements or restriction of access to medical information

Yes (Must provide legal paperwork) No

Previous doctor/office

Have you requested records

Yes No

Last routine physical

Other doctor's/dentists involved in your child's care (include specialty)

Birth History

Hospital

Birth weight

please select one

on time early late

Health issues during preganancy

Difficulties after birth (jaundice, infection, feeding problems...)

Medical History

Hospitalizations

Surgeries

Recurring illness (ear infections, wheezing...)

Major Accidents/injuries

Medications, including vitamins and supplements your child is currently taking

Family History

mother (M) father (F) brother (B) sister (S) aunt (A) uncle (U)
mother's mother (MM) mother's father (MF) father's mother (FM) father's mother (FF)

Which family members have the following? (please indicate using the above abbreviations)

Allergies

Asthma

Arthritis

Anxiety

Autism

Birth Defects

Blood disorder

Hearing loss

Depression

Diabetes

Developmental Delay

Drug abuse or Addiction

Cancer (what type)

Intestinal Disorder/Ulcer/GERD

Heart Disease

High Blood Pressure

High Cholesterol

Kidney Disease

Migraines

Seizures

Stroke

Sudden Unexplained Death

Other

Tuberculosis Exposure:

Has your child visited Africa, Latin America or Eastern Europe in the last year?

Yes No

Has your child been exposed to anyone with Tuberculosis?

Yes No

Has your child had close contact with anyone with a positive TB skin test (PPD)?

Yes No

Does your child have a household member that travels outside the US?

Yes No

Does your child have close contact with anyone who has been in prison, a shelter, a nursing home, that uses illegal drugs or has HIV/AIDS?

Yes No

Signature of Parent/Guardian

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