New Patient Medical History - Newborn to 6 Month Old

New Patient Medical History - Newborn to 6 Month Old
THIS FORM MUST BE COMPLETED AND RETURNED BEFORE 1ST VISIT

*WE DO REQUIRE IMMUNIZATION RECORDS BEFORE WE CAN ADMINISTER ANY VACCINES*

The following is very important to your child's health.

Please complete it accurately and completely.
Child's name
Birth date

MonthDayYear
Date
Which hospital was your child born?
Is child adopted or fostered?

YesNo
Has your child ever previously been seen by any of the doctors in this practice?

YesNo
Family - Past Medical History

Follow each question listed below and if you mark yes, you will receive another question following the previous that must be answered.
Nasal allergies or other allergies

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Asthma/lung Disease

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Heart Disease or heart condition

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
High blood pressure

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
High cholesterol

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Diabetes or other endocrine problem

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Cancer

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Anemia

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Bleeding disorder

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Epilepsy or convulsions

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Mental retardation or developmental disorders

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Neurological disorder including

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
ADHD/ADD

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Liver disease

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Other GI disease / disorder

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Kidney disease

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Bed-wetting (after age 10)

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Hearing impairment

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Vision impairment or eye disorder

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Immune problems, recurrent infections or HIV-AIDS

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Alcohol Abuse

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Drug Abuse

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Mental Illness

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Tuberculosis

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Migraine Headaches

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Thyroid Disease

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Intestinal ulcers, colitis, gast, reflux

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Autoimmune disorder: lupus or rheumatoid arthritis

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Other Issues & Biological Relative
Social History
Does the child live with both mother and father in the same house? (If no, explain the situation and the visitation status of non-custodial parent)

YesNo
Are there siblings?

YesNo
Are there pets in the home?

YesNo
Are there smokers in the home? (If yes - explain who)

NoYes
Are there guns in the home? (If yes - explain)

NoYes
Are guns locked and kept separate from ammunition? (If yes - explain)

NoYes
Other Issues:
Was the baby born at Gadsden Regional Medical Center?

YesNo
Baby's weight in pounds then ounces
Baby's birth length in inches
Fill out the question about the babies history at birth and explain if necessary
Resuscitation at delivery (needed help to start breathing/crying)? (If Yes, please explain)

NoYes
Premature infant? (If Yes, please explain)

NoYes
Did NOT get vitamin K and / or eye prophylaxis? (If Yes, please explain)

NoYes
Feeding: Breast milk or formula? Or both? (If Yes, please explain)

NoYes
Hypoglycemia (low blood sugar)? (If Yes, please explain)

NoYes
Hypothermia (low temperature)? (If Yes - explain)

NoYes
Sepsis screening labwork (to check for infection)? (If Yes - explain)

NoYes
Elevated Bilirubin (jaundice)? (If Yes - explain)

NoYes
Circumcision? (If Yes - explain)

NoYes
Delayed passage of first bowel movement? (If Yes - explain)

NoYes
Heart Murmur? (If Yes - explain)

NoYes
Breathing problems? (If Yes - explain)

NoYes
Needed oxygen or help breathing? (If Yes - explain)

NoYes
Needed antibiotics while in nursery? (If Yes - explain)

NoYes
Apnea (stopping breathing)? (If Yes - explain)

NoYes
Needed head ultrasound? (If Yes - explain)

NoYes
Needed ophthalmologic (eye) exam? (If Yes - explain)

NoYes
Other Issues:
Fill out the question about the mothers prenatal history and explain if necessary
Was this an assisted conception (had to have help getting pregnant)? (If Yes - explain)

NoYes
Was this a High Risk Pregnancy? (If Yes - explain)

NoYes
Did you have Amniocentesis / CVS? (If Yes - explain)

NoYes
Did you have little or late prenatal care? (If Yes - explain)

NoYes
Did you use alcohol or tobacco while pregnant? (If Yes - explain)

NoYes
Did you use any non-prescription drugs while pregnant? (If Yes - explain)

NoYes
Was there any problem with your maternal health? (If Yes - explain)

NoYes
Was there any problem with the baby before born? (If Yes - explain)

NoYes
Water broke more than 24 hours before delivery? (If Yes - explain)

NoYes
Did you have antibiotics or other medications during labor? (If Yes - explain)

NoYes
Was your labor induced (started by medications)? (If Yes - explain)

NoYes
Was this delivery vaginal or by C-section? (If Yes - explain)

NoYes
Was there meconium (green bowel movement) present when your water broke? (If Yes - explain)

NoYes
Other Issues:
Is there anything else regarding your child's health that you think we should know that has not already been asked?
Is there anything else regarding your child's health that you think we should know that has not already been asked?
I attest that all the medical history information is true and correct to the best of my knowledge:
Signature

Clear
Relationship to patient
Print Name
Today's Date

MonthDayYear
Date
Should be Empty:

New Patient Medical History - Newborn to 6 Month Old

THIS FORM MUST BE COMPLETED AND RETURNED BEFORE 1ST VISIT

Family - Past Medical History

Social History

Fill out the question about the babies history at birth and explain if necessary

Fill out the question about the mothers prenatal history and explain if necessary