PEDIATRIC HEALTH HISTORY QUESTIONNAIRE

Patient Information (May be requested annually)

Patient’s Name:

Gender:

Male Female

Pref. or Nickname:

Date of Birth:

Home Phone:

Address:

Please select:

Child Mother Father

Cell Phone:

Please select:

Child Mother Father

Cell Phone:

Other Children Seen Here

Name:

Date of Birth:

Gender:

Male Female

Add new row

Parent(s) or Guardian(s) Information

Parent #1 / Financially responsible:

SS #:

Relationship to patient:

DOB:

Employer:

Occupation:

E-mail address:

Home Phone:

Cell Phone:

Work Phone:

Address if different from child:

Parent #2:

SS #:

Relationship to patient:

DOB:

Employer:

Occupation:

E-mail address:

Home Phone:

Cell Phone:

Work Phone:

Address if different from child:

Insurance Subscriber:

Date of Birth:

Nearest relative NOT living with you:

Name:

Phone:

Address:

City:

State:

ZIP:

Your signature allows us to use electronic prescription verification.

I agree to pay the charges for the medical care of the above named child.
I authorize Health Care for Children PC to furnish my insurance company with medical records.
I also authorize my insurance company to pay Health Care for Children PC directly.
I understand my insurance policy is a contract between my insurance company and myself and that Health Care for Children PC files insurance as a courtesy.
I also understand that if my insurance company does not pay within 90 days, I will be billed

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name of Parent or Guardian:

Date:

MEDICAL HISTORY

Patient Name:

DOB:

Past Medical History:

Birth weight:

Due date:

Pediatrician at birth:

Place of birth:

Time of Birth:

Problems during pregnancy, labor, delivery:

Problems with baby after delivery:

Type of delivery (Vaginal, C-Sections, Forceps etc):

Nutrition:

Breastfeeding:

Bottlefeeding:

Breastmilk/formula:

Please select:

Asthma

Developmental Issues

Psychiatric Illness

Behavioral Issue

Hospitalizations

Seizures

Other

Asthma

Yes No

Developmental Issues

Yes No

Psychiatric Illness

Yes No

Behavioral Issues

Yes No

Hospitalizations

Yes No

Seizures

Yes No

Other:

Past Surgical History

Adenoidectomy

Yes No

Circumcision

Yes No

Myringotomy Ear Tube(s)

Yes No

Appendectomy

Yes No

Eye Surgery for Strabismus

Yes No

Tonsillectomy

Yes No

Other:

Allergy:

Medications:

Foods:

Environmental:

Family Medical History:

Adopted

Yes No

Family History of Allergies

Yes No

Family History of Cancer

Yes No

Family History of Eczema

Yes No

Family History of Heart Disease/High Cholesterol

Yes No

Family History of Asthma

Yes No

Family History of Diabetes

Yes No

Other:

Social History:

Stay at home with family member Childcare In Home Setting Daycare

Participates in Competitive Sports

Yes No

School:

Grade Home School

PHARMACY REFERENCE

PHONE:

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