* = Required Information
PEDIATRIC HEALTH HISTORY
Your child's health is of utmost importance to us. Please fill out this form as completely and accurately as you can. If you are unsure of how to answer a certain item, just circle the item and we will be happy to discuss it with you. All information will be treated confidentially.
Date
*
SS/HIC/Patient ID #
Child's Name
*
Child's Sex
*
Date of Birth
*
Age
*
Mother's Name
*
Phone: Home
Work
Father's Name
*
Phone: Home
Work
Home Address
*
E-mail Child's School
*
Phone: Cell #1
Cell #2
Child's School
Grade
Previous Physician
City/State
Phone
ALLERGIES
Substance
Reaction
MEDICATIONS
Medication Name
Dosage
MEDICAL HISTORY
Please check (
) if child has ever had any of the following:
Anemia
Asthma
Bronchitis/Bronchiolitis
bronchopulmonary Dysplasia (BPD)
Chicken Pox
Hepatitis
Immune Deficiency/HIV
Measles (1-day)
Measles, Rubella (3-day)
Mumps
Prematurity
Rheumatic fever
Pneumonia
Sickle Cell Diease
Whooping cough
Other
GENERAL
Chills
Despression
Dizziness
Fainting
Forgetfulness
Headache
Loss of sleep
Mood swings
Nervousness
Numbness
Sweating
Tiredness
Weight loss/gain
CARDIOVASCULAR
Breathing problems
Chest pain
Irregular heart beat
EYES
Crossed or wandering eyes
Eye irritation
Headaches
Vision problems
HEARING/SPEECH
Difficulty hearing
Earache
Ear infections
Hoarseness
Speech problems
DENTAL
Bleeding gums
Grinding teeth
Sensitivity to hot/cold
Thumb-sucking
Last dental check-up
Date
Brush, how often?
Floss, how often?
GASTROINTESTINAL
Appetite poor
Bloody or dark stools
Constipation
Diarrhea
Excessive hunger
Excessive thirst
Nausea
Rectal bleeding
Stomachaches
Vomiting
Worms
GENITO-URINARY
Bed-wetting
Blood in urine
Diaper rash, persistent
Discharge from vagina or penis
Frequent urination
Painful urination
Unusual urine odor
MUSCLE/JOINT/BONE
Broken bones or sprains
Coordination problmes
Posture problems
Pain, weakness, swelling in:
Arms
Hips
Back
Legs
Feet
Neck
Hands
Shoulders
NOSE/THROAT/CHEST
Difficulty breathing
Difficulty swallowing
Frequent colds
Hoarseness
Mouth-breathing
Nosebleeds
Persistent cough
Sinus problems
Sore throat
Tonsil infections
Wheezing
SKIN
Bruise easily
Change in moles
Hives
Itching
Rash
Scars
Sores that wont heal
DIETARY ASSESSMENT
How often does your child eat the following:
3 Times Daily
Dialy
Weekly
Monthly
Beans, peas
Breads, crereals, grains
Candy
Dairy products
Eggs
Fruits
Meats
Poltry, fish
Sodas
Vegetables, green
Vegetables, yellow
What vitamin supplements does your child take?
How often?
Is there fluoride in your water?
Yes
No
HOSPITALIZATIONS
Reason
Date
Hospital, City, State
INJURIES
Serious Injuries/Illnesses
Date
Outcome
Has your child ever had a blood transfusion?
Yes
No
IMMUNIZATIONS
Please check (
) whether or not your child has been given the following immunizations. If yes, please fill in the date(s) given.
YES
NO
DATE
Hepatitis B
DPT, series of 3 shots
DPT booster shots
Hib (Influenza)
YES
NO
DATE
Polio shots, series of 3
Polio booster shots
Polio by mouth, series of 3
PCV7 (Pneumococcal)
YES
NO
DATE
Measles Vaccine
Mumps Vaccine
Rubella Vaccine
Chicken Pox Vaccine
FAMILY HISTORY
Please give the following information about your child's immediate family:
Age
General Health
Father
Mother
Have any your childeren died?
Yes
No
Age
General Health
Sibling
M
F
Sibling
M
F
Sibling
M
F
Please check (
) conditions that any of the child's blood relatives (including parents and siblings) have had ang the relatioship to the child:
Condition
Relationship
Condition
Relationship
Alcoholism
HIV/AIDS
Allergies
Kidney disease
Anemia
Lung disease
Arthristis
Mental disease/disorder
Asthma/emphysema
Mental retardation
Birth defects
Muscle disorders
Bone/joint disorders
Rheumatic fever
Cancer
Seizures/convulsions
Diabetes
Sickle cell anemia
Epilepsy
Skin disease
Eye or ear disorders/Hearing loss/Blindness
Stroke
Genetic defects
Thyroid disease
Heart disease
Tuberculosis
Hemophilia
Venereal disease
High blood pressure
Other
PRE-NATAL AND INFANT HEALTH HISTORY
Place of birth
Obstetrician
Mother's age at birth
During the pregnancy which conditions did you have? Please (
) all that apply:
Alcohol use
Exposure to chemical or radiation
Anemia
Fever
Diabetes
German measles
Drug use, non-prescription drug (Please list)
Hepatitis
Drug use, prescription drug (Please list)
High blood pressure
Drug use, controlled drug such as narcotics (Please list)
Protein in urine
Edema
Tabacco use
Urinary disease
Venereal disease
Other illnesses or infections
DELIVERY
Please check (
) all that apply
On time
Premature
Late
Normal
Induced
Prolonged
Breech
C-Section
Please describe
INFANT HEALTH
Birthweight
Length
Discharge weight
Age when dischanged
INFANT HEALTH PROBLEMS
Please check (
) and describe.
Birth defects
Breathing problems
Infection
Jaundice
Transfusion
Other
FEEDING
Breast fed
Formula fed
DEVELOPMENTAL
Please note age at which your child:
Lefted head
Wk.
Rolled over
Mo.
Cooed/Laughed
Mo.
Sat up
Mo.
Stood up
Mo.
Walked
Mo.
Finger fed
Mo.
Drank from cup
Mo.
Spoon fed
Mo.
First word
Mo.
Toilet trained
Mo.
Dressed self
Mo.
EDUCATION AND SOCIAL HISTORY
Please explain any problems or concerns you have about your child in any of the following areas:
Appearance/Weight/Height
Behavior
Friends
Grades/learning ability
Sexuality
How many hours per day does your child watch television or play video games?
Get exercise?
Do you suspect that your child is involved with:
Drugs
Alcohol
Tobacco
None
Have you noticed any of the following warning signs of drug abuse:
Angry behavior
No
Yes
Depression
No
Yes
Changes in appearance
No
Yes
Signs of drugs in the house
No
Yes
Changes in attitude
No
Yes
Skipping school
No
Yes
Changes in friendships
No
Yes
Withdrawal from friends or family
No
Yes
CHILD SAFETY INVENTORY
Adequate number of working smoke alarms?
Yes
No
Safety plugs in unused wall sockets?
Yes
No
Does child use car seat/seat belt?
Yes
No
Safety gate for stairs?
Yes
No
Medicines cleaning supplies, chemicals out of reach?
Yes
No
Know dangers of peeling paint, mice/rats in the home?
Yes
No
Syrup of Ipecac in the home?
Yes
No
Does child know how to swim?
Yes
No
Know poison control phone number?
Yes
No
Are guns in the home in locked storage?
Yes
No
Water heater set below 120F?
Yes
No
Does child use bicycle helmet?
Yes
No
PARENT CONCERNS
Reason for visit today and any other concerns or questions you have about your child.
To the best of my knowledge, the above information is complete and correct. I understand the reporting incomplete or inaccurate information can be dangerous to my child's health. I understand that I am solely reponsible for any errors or omissions that I may have made in the completion of this form. I understand that it is my responsibility to inform my doctor if my minor child ever has a change in health.
Date
Please print name of Parent, Guardian or Personal Representative
Relationship to Patient
DR. COMMENTS
Physician Name
Date
UPDATES
(To be filled in at future appointments)
Has there been any change in child's health since last appointment?
Yes
No
Please describe
Parent/Guardian Name
Date
Physician Name
Date
Has there been any change in child's health since last appointment?
Yes
No
Please describe
Parent/Guardian Name
Date
Physician Name
Date
Has there been any change in child's health since last appointment?
Yes
No
Please describe
Parent/Guardian Name
Date
Physician Name
Date
*
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