Medical History
Patient Name
*
First Name
Last Name
Patient Date of Birth
-
Month
-
Day
Year
Date
Patient Gender
Male
Female
Form Completed By
Date Completed
-
Month
-
Day
Year
Date
Household
Please list all those living in child's home.
Birth History
Birth Weight
Which Hospital was your child born?
Was the delivery:
Vaginal
Cesarean
Any problems after birth?
Do you consider your child to be in good health? If NO, explain.
Has your child had any surgery? If yes, explain.
Is your child allergic to any medicines or drugs? If yes, please list.
Any hospital admissions?
Family History
If your family has had any of the following please answer each one and if yes please provide who in the family and any additional explanation at the end of the list.
Deafness
Yes
No
Nasal allergies
Yes
No
Asthma
Yes
No
Tuberculosis
Yes
No
Heart Disease (before 50 years old)
Yes
No
High blood pressure(before 50 years old)
Yes
No
High Cholesterol
Yes
No
Anemia
Yes
No
Bleeding disorder
Yes
No
Liver disease
Yes
No
Kidney disease
Yes
No
Diabetes (before 50 years old)
Yes
No
Bed-wetting (after 10 years old)
Yes
No
Epilepsy or convulsions
Yes
No
Alcohol Abuse
Yes
No
Drug Abuse
Yes
No
Mental Illness
Yes
No
Immune problems, HIV or AIDS
Yes
No
If you answered yes to any of the above, please identify who in the family and any additional explanation.
Is there anything in your child's past history that we need to know about? Please explain.
Development
If you answer yes to any of the following questions, please explain after the questions.
Are you concerned about your child's physical development?
Yes
No
Are you concerned about your child's mental or emotional development?
Yes
No
Are you concerned about your child's attention span?
Yes
No
If you answered yes to any of the above 3 questions, please explain.
If your child is in school, how is he/she doing? Has he/she ever repeated a grade or received special resources? Please explain.
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