PAST MEDICAL HISTORY FORM

(2 MONTHS AND OLDER)

Child's Name:

Birth date:

Nick Name/Preferred Name:

Previous pediatrician:

City:

State:

Referred by:

Mother’s name:

Occupation:

Age:

Father’s name:

Occupation:

Age:

Sibling’s name:

Medical problems:

Age:

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Parent’s marital status:

Married Single Separated Divorced Other

If other, please specify:

Who does the child live with?

Does anyone in the home smoke cigarettes, drink alcohol or use street drugs?

Yes No

Does your family or the child observe any special diets?

Yes No

Any religious / spiritual affiliations?

What daycare/school does your child attend?

Any concerns at school or daycare (learning or behavior)?

Any hobbies or sports?

CHILD’S MEDICAL HISTORY:

Hospital of delivery:

Please select:

Vaginal delivery C-section

Birth weight:

Gestational Age (number of weeks):

Complications at birth?

Allergies:

Current meds:

Hospitalizations:

Reason:

Date:

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Surgery including circumcision:

Type:

Date:

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Immunizations up to date? (please give immunization to medical assistant)

Add file

Please upload a file

Current Medical Conditions or Concerns:

Has your child ever had or been treated for the following:

Allergies, sinus

Yes No

Anemia

Yes No

Behavior problems/ADHD

Yes No

High blood pressure

Yes No

High Cholesterol

Yes No

Bowel problems

Yes No

Thyroid problems

Yes No

Depression / psychiatric

Yes No

Food allergy/intolerance

Yes No

Wheezing, asthma, bronchitis

Yes No

Eczema or skin problems

Yes No

Heart problems

Yes No

Hepatitis or liver problems

Yes No

Diabetes

Yes No

Kidney problems

Yes No

Seizures

Yes No

Chicken pox

Yes No

Date:

Positive PPD/TB test

Yes No

Date:

FAMILY HISTORY:

Has anyone in the family ever had or been treated for the following? (Include the child’s siblings, mother, father, grandparents, aunts and uncles.)

Allergies, sinus

Yes No

If yes, with whom:

Anemia

Yes No

If yes, with whom:

Positive PPD/TB

Yes No

If yes, with whom:

High blood pressure

Yes No

If yes, with whom:

High blood pressure

Yes No

If yes, with whom:

High Cholesterol

Yes No

If yes, with whom:

Bowel problems

Yes No

If yes, with whom:

Thyroid problems

Yes No

If yes, with whom:

Depression / psychiatric

Yes No

If yes, with whom:

Stroke

Yes No

If yes, with whom:

Cancer

Yes No

If yes, with whom:

Food allergy/intolerance

Yes No

If yes, with whom:

Wheezing, asthma, bronchitis

Yes No

If yes, with whom:

Eczema or skin problems

Yes No

If yes, with whom:

Heart problems

Yes No

If yes, with whom:

Hepatitis or liver problems

Yes No

If yes, with whom:

Diabetes

Yes No

If yes, with whom:

Kidney problems

Yes No

If yes, with whom:

Drug or alcohol problems

Yes No

If yes, with whom:

Seizures

Yes No

If yes, with whom:

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