Family Medical History (Individual)

Family Medical History

Bloom Pediatrics • 2055 E 14 Mile Road, Birmingham, MI 48009 • (248) 645-1740
Patients

List the name and date of birth for each child in your family who is a patient.
How many children in the family are patients?
Patient 1 Name*
Patient 1 Date of Birth*

MonthDayYear
Date
Patient 2 Name
Patient 2 Date of Birth

MonthDayYear
Date
Patient 3 Name
Patient 3 Date of Birth

MonthDayYear
Date
Patient 4 Name
Patient 4 Date of Birth

MonthDayYear
Date
Patient 5 Name
Patient 5 Date of Birth

MonthDayYear
Date
Patient 6 Name
Patient 6 Date of Birth

MonthDayYear
Date
Does your child or any of your child's biological parents, siblings, or grandparents have the following conditions for which they are followed by a doctor or treated with medications regularly? Please check all that apply.
Conditions

ADHDAllergiesAnemiaAsthmaArthritis or Autoimmune DiseaseAutism or Developmental DisabilityBedwetting After 7 Years OldBleeding or Clotting DisordersCancerChildhood Hearing Loss/DeafnessColitis (Crohn’s, Ulcerative Colitis, Celiac Disease)Depression, Anxiety, or Other Mental IllnessDental Decay or Significant CavitiesDiabetesDrug/Alcohol AbuseEczema/Skin DisordersEpilepsy or SeizuresHeart Disease Before 55 Years OldHigh Blood PressureHigh CholesterolHip DysplasiaKidney DiseaseLazy Eye/StrabismusLearning DisabilityLiver DiseaseMigraine HeadachesNeurologic Disorders (Seizures, Multiple Sclerosis, Other)ObesityStroke before 55 years oldSudden Death Before 55 Years OldSuicideThyroid DisordersTobacco Use/VapingTuberculosis
For each selected condition, list the biological relatives with the condition and provide any additional details.

If you select "Patient or Sibling", please specify the person's name in the Details/Comments field.
ADHD*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Allergies*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments*
List known allergies here (medications, foods, hay fever, etc)
Anemia*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Asthma*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Arthritis or Autoimmune Disease*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Autism or Developmental Disability*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Bedwetting After 7 Years Old*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Bleeding or Clotting Disorders*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Cancer*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments*
Please specify the type of cancer
Childhood Hearing Loss/Deafness*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Colitis (Crohn’s, Ulcerative Colitis, Celiac Disease)*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments*
Please specify the type of disease
Depression, Anxiety, or Other Mental Illness*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments*
Please specify the type of mental illness
Dental Decay or Significant Cavities*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Diabetes*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments*
Please specify adult or child onset
Drug/Alcohol Abuse*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Eczema/Skin Disorders*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Epilepsy or Seizures*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Heart Disease Before 55 Years Old*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
High Blood Pressure*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
High Cholesterol*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Hip Dysplasia*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Kidney Disease*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Lazy Eye/Strabismus*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Learning Disability*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Liver Disease*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Migraine Headaches*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Neurologic Disorders (Seizures, Multiple Sclerosis, Other)*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments*
Please specify the type of disease
Obesity*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Stroke Before 55 Years Old*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Sudden Death Before 55 Years Old*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Suicide*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Thyroid Disorders*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Tobacco Use/Vaping*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Tuberculosis*

Patient or SiblingMotherFatherMaternal GrandparentPaternal Grandparent
Details/Comments
Should be Empty:

Family Medical History

Patients