Pediatric Associates of Wellesley Medical History Form

Dear Parent,
This is a health questionnaire for your child. Please complete this form and bring it with you at the time of your first appointment.

Child's Name:

Date of Birth:

Date Completed:

Family History

Mother's Name:

Age

Occupation

Past Health Problems (If any)

Father's/Partner's Name

Age

Occupation

Past Health Problems (If any)

Martial Status of Parents

Other Children in Family

Name

Date of Birth

State of Health

Name

Date of Birth

State of Health

Name

Date of Birth

State of Health

Name

Date of Birth

State of Health

Are there cultural or religious practices that might affect your child's medical care?

Yes

If yes, please explain (Ex: Blood transfusion, dietary rules, etc)

Is there a history in the family / blood relative with Tuberculosis?

Yes

Diabetes

Yes

Asthma / Hay fever / Eczema / Allergies

Yes

Psychiatric Disorder

Yes

Substance Abuse

Yes

Celiac Disease

Yes

Heart Disease / Stroke / High Cholesterol

Yes

Cancer

Yes

If Yes, what kind? (Cancer)

Birth Defects / Genetic Defects

Yes

Melanoma

Yes

Autism

Yes

Prenatal History

Were there any problems during the delivery or pregnancy of your baby?

Was the baby born early? (Less than 38 weeks)

Yes

Was the baby born late? (More than 42 weeks)

Yes

Did the baby remain in the hospital longer than the mother?

Yes

Birth weight of baby

How was the baby fed?

Breast

Bottle

Developmental History

Has your previous pediatrician ever had concerns about your child's development? If yes, please explain.

Immunizations

Please give us a copy of previous immunizations/Vaccines and TB (Tuberculosis) testing and Lead test results.

Past Medical History - Has the child had:

Hospitalizations

Yes

If yes, what illness?

Surgeries

Yes

If yes, for what?

Other serious medical illnesses

Yes

If yes, what kind?

Is your child currently taking any medications, vitamins or herbs?

Yes

Medication

Doses

How often?

Medication

Doses

How often?

Medication

Doses

How often?

Reaction to drugs or foods

Yes

If yes, please explain

Are there concerns about physical, sexual or emotional abuse?

Yes

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