Medical History Form

Patient Name:

Date of Birth:

PAST MEDICAL HISTORY

Birth Weight Lbs

Birth Weight Oz

Born within 3 weeks of due date?

Yes No

Mother's age at birth:

How many pregnancies?

Complications of pregnancy or delivery, if any (including medications)

Date of last check up:

Date of last dental check up

Has your child had allergic reactions to any medications, food, or insect bites?

Yes No

If so, what?

Does your child have any chronic illness or medical problems

Yes No

If so, explain:

Any hospitalizations other than for birth?

Yes No

If so, for what?

Any surgery or serious injuries?

Yes No

If so, what kind?

Are any medications taken regularly?

Yes No

Which ones?

Are immunizations up to date?

Yes No

Is or was your child breastfed?

Yes No

Commercial formula used?

Yes No

If so what kind and duration of bottle use?

The following information about family will help us know and understand your child better.

Mother's Name:

Mother's Age:

Mother's Occupation:

Father's Name:

Father's Age:

Father's Occupation:

Do both biological parents live in the household?

Yes No

If not, please explain:

Does your child attend school and/or child care outside the home?

Yes No

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

Yes No

Are there any smokers in the household?

Yes No

Are there any problems with the condition of your home (peeling paint, insects, rats or mice)?

Yes No

Other:

Does your child always wear a helmet when riding his/her bicycle?

Yes No

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

Yes No

FAMILY MEDICAL HISTORY

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Patient Name:

Date:

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