Patient History
Today's Date
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Month
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Day
Year
Date
Patient Name
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First Name
Middle Name
Last Name
Patient Date of Birth
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Month
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Day
Year
Date
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What kind of home does the child live in?
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House
Apartment
Condo
Shelter
Other
Was your home built before 1970?
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Yes
No
Does the child's father work?
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Yes
No
Please list the occupation of the child's father.
Does the child's mother work?
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Yes
No
Please list the occupation of the child's mother.
Does your home have any of the following?
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None
Smoke Detectors
Hot Tub
Carbon Monoxide Detectors
Pool
Nearby lake, pond, or stream
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Does your child go to daycare?
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Yes
No
Which type of daycare does your child attend?
Relative
Before/After School Program
Nanny/In House Sitter
Licensed Daycare Center
Private Home (Licensed)
Private Home (Unlicensed)
Does your child go to school?
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Yes
No
Homeschool
School Name
Child's Grade in School
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Perinatal History
Where was the child born?
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Hospital & City
Child's Birth Weight
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XX lbs, XX oz
Was the child premature?
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Yes
No
If yes, how many weeks early?
Any problems during the pregnancy?
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Yes
No
If yes, please explain:
How was the child delivered?
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Vaginally
C-Section
Any problems during delivery?
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Yes
No
If yes, please explain:
Did the child need any special help after delivery?
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Yes
No
If yes, what?
Oxygen
Jaundice Lights
Antibiotics
Other
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Past Medical History
Please check all that apply for the child:
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Serious injuries or accidents
Surgeries
Hospitalizations
Chicken Pox
Frequent Ear Infections
Problems with Ears or Hearing
Asthma, Bronchitis, Pneumonia
Animals
Outdoor Allergens
Indoor Allergens
Heart problems
Heart murmur
Anemia or bleeding problem
Blood transfusion
Frequent abdominal pain
Constipation requiring doctor visits
Bladder or kidney infection
Bed-wetting (after 5 years of age)
Chronic or recurrent skin problems (acne, eczema, etc.)
Frequent headaches
Convulsions or other neurologic problems
Diabetes
Thyroid or other endocrine problems
Use of alcohol or drugs
Other significant problems
None
Has your child ever been hospitalized overnight since birth?
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Yes
No
When did the hospitalization(s) occur and for what reason?
Has your child ever had any surgeries?
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Yes
No
When did the surgeries occur and for what reason?
Comments on any other selected items above:
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Social History
Who does the child with?
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Mother
Father
Relative/Guardian
Other
If relative/guardian or other, please specify:
Parents are:
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Married
Divorced
Separated
Single
If parents are not together, what is the custody arrangement?
Does the child have siblings?
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Yes
No
Please list the names, sex, and age of siblings. Also, if full, half, step, or adoptive siblings.
Do you have pets in the home?
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Yes
No
If yes, please list all pets:
Does anyone smoke in the home?
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Yes
No
If yes, please list who in the home is a smoker:
Do you have guns in the home?
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Yes
No
If yes, are the guns locked/secured?
Yes
No
If yes, are the guns stored separately from ammunition?
Yes
No
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Are there any potential stress issues in your home? (check all that apply)
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None
Alcoholism
Chronic illness
Disability
Domestic violence
Drug use
Financial difficulties
Marital difficulties
Mental health issues
Recent death in the family
Unsafe neighborhood
Other
If you checked other, please explain or specify:
Does your child have any allergies?
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Yes
No
Please list your child's allergies.
Dos your child take any medications? (Please include vitamins & herbal medicines))
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Yes
No
Please list the medications:
Has your child received immunizations?
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Yes, up to date.
Yes, but behind schedule.
No, none.
If your child is behind or has not received immunizations, please list what shots and why.
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Should be Empty: