Pediatric Medical History Form

Your answers on this form will help your provider understand your child's medical history.

Child's Name

Date of Birth

Person Completing Form/Relationship

Date of Form Completion

Medications

Medication

Prescribing Provider

Dose

How many times a day

Medication

Prescribing Provider

Dose

How many times a day

Medication

Prescribing Provider

Dose

How many times a day

Medication

Prescribing Provider

Dose

How many times a day

Medication Allergies

Yes No

If yes, to what medication(s)

What was the reaction

Immunization History

(Please supply a copy of your child's immunization record)

To the best of my knowledge, my child is up to date on his/her immunizations

Yes No

If no, why?

Birth History

Please indicate any medical problems during pregnancy

Please list any medications taken during the pregnancy

Any drug or alcolhol use during the pregnancy?

Yes No

If yes, please specify

Delivered by

elective c-section emergent c-section forceps vacuum extraction normal vaginal delivery

If not a normal vaginal delivery, why?

Number of weeks gestation

Birth weight

Discharge weight

Did the baby receive the Hepatitis B vaccine?

No Yes

If yes, date given

Please indicate any medical problems during the newborn period

Name of hospital where infant was born

Personal Medical History

Hospitalizations

Has your child ever stayed overnight in a hospital?

Yes No

If yes, when and why?

Surgical History/Outpatient Procedure History (ex: ear tubes, tonsillectomy, etc)

Please indicate any surgeries or procedures your child has had. Please include the year the surgery/provedure was performed.

Other Procedures:

(Please list any other specialists your child sees. Ex: physical therapy, ENT, etc)

Gyn History

Age of first period

Has not had menses yet

Yes No

Family History

Please indicate if your child has a family history (parents, siblings, grandparents, aunts, or uncles) of any of the following: ** Please specify maternal/paternal relation

ADD/ADHD

Family Member

Alcohol/Drug Abuse

Family Member

Allergies

Family Member

Asthma

Family Member

Birth defects

Family Member

Blood disorders

Family Member

Cancer, type

Family Member

Heart disease

(heart attack, bypass, stents)

Family Member

Deafness/Hearing problems

Family Member

Depression

Family Member

Developmental delay

Family Member

Diabetes

Family Member

Genetic Disorder

Family Member

Hepatitis/Liver disease

Family Member

Hearing disability

Family Member

High cholesterol

Family Member

High blood pressure

Family Member

HIV/AIDS

Family Member

Learning Disability

Family Member

Mental Illness

Family Member

Mental retardation

Family Member

Migraines

Family Member

Scoliosis

Family Member

Seizure disorder

Family Member

Speech problems

Family Member

TB/Lung disease

Family Member

Stroke

Family Member

Thyroid disease

Family Member

Other

Family Member

Is the child cared for by anyone other than the biological parents?

Yes No

If yes, by whom and how frequently?

Does anyone in your home smoke?

Yes No

Parent

Date

Your information will be encrypted.