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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? YesNo HOSPITALIZATIONS Reason Date Hospital, City, State   INJURIES Serious Injuries/Illnesses Date Outcome Has your child ever had a blood transfusion? YesNo 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? YesNo   Age General Health   Sibling MF Sibling MF Sibling MF 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 NoYes Depression NoYes Changes in appearance NoYes Signs of drugs in the house NoYes Changes in attitude NoYes Skipping school NoYes Changes in friendships NoYes Withdrawal from friends or family NoYes CHILD SAFETY INVENTORY Adequate number of working smoke alarms? YesNo Safety plugs in unused wall sockets? YesNo Does child use car seat/seat belt? YesNo Safety gate for stairs? YesNo Medicines cleaning supplies, chemicals out of reach? YesNo Know dangers of peeling paint, mice/rats in the home? YesNo Syrup of Ipecac in the home? YesNo Does child know how to swim? YesNo Know poison control phone number? YesNo Are guns in the home in locked storage? YesNo Water heater set below 120F? YesNo Does child use bicycle helmet? YesNo 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? YesNo Please describe Parent/Guardian Name Date Physician Name Date Has there been any change in child's health since last appointment? YesNo Please describe Parent/Guardian Name Date Physician Name Date Has there been any change in child's health since last appointment? YesNo Please describe Parent/Guardian Name Date Physician Name Date
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