Medical History Form

Patient First Name:

Patient Last Name:

Date of Birth:

Comments:

Family medical history:

Using the key given, please list any/all blood relatives (in relation to the child) who have had any of the following conditions:

MAT = Maternal
PAT = Paternal
MO = Mother
FA = Father

SIB = Sibling
AU = Aunt
UN = Uncle
CN = Cousin

GM = Grandma
GP = Grandpa
GGM = Great Grandma
GGP = Great Grandpa

Nasal allergies, other allergies, eczema, etc.

Yes No

Relationship:

Asthma or lung disease

Yes No

Relationship:

Heart disease or heart condition

Yes No

Relationship:

High blood pressure

Yes No

Relationship:

High cholesterol

Yes No

Relationship:

Diabetes or other endocrine problem

Yes No

Relationship:

Cancer

Yes No

Relationship:

Anemia

Yes No

Relationship:

Bleeding disorders

Yes No

Relationship:

Epilepsy or convulsions

Yes No

Relationship:

Mental retardation or developmental disorders

Yes No

Relationship:

Neurologic disorder including ADHD/ADD

Yes No

Relationship:

Liver disease

Yes No

Relationship:

Other GI disease/disorder

Yes No

Relationship:

Kidney disease

Yes No

Relationship:

Bed-wetting (after 10 years of age)

Yes No

Relationship:

Hearing impairment

Yes No

Relationship:

Vision impairment or eye disorder

Yes No

Relationship:

Immune problems, recurrent infections, or HIV/AIDS

Yes No

Relationship:

Alcohol abuse

Yes No

Relationship:

Drug abuse

Yes No

Relationship:

Mental illness

Yes No

Relationship:

Tuberculosis

Yes No

Relationship:

Additional pertinent conditions

Yes No

Relationship:

Comments:

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Name of person completing form:

First Name:

Last Name:

Date:

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