* = 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? 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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