Comfort Care Pediatrics Patient History Form

	Full Term	# Weeks Early	Vaginal	C-Section	Birth Weight
Birth History

List Any Complications During Pregnancy
Number of Days In Hospital:
Daily Medications:
Medication Allergies:
Past Medical History: Check the box if your child has had any of the following? If so, give brief description and dates.

Type a question

	Past Occurrence	Background Information and Dates Occurred
Serious Injuries Accidents
Concussion
Stitches or Broken Bones
Surgeries
Hospitilizations
Frequent Ear/ Sinus Infections
Frequent Tonsilitis / Strep
Other Infectious Illnesses
Animal Allergies
Outdoor Allergies
Indoor or Food Allergies
Asthma or Bronchitis
Pneumonia or Croup
Heart Problems / Murmur
Abdominal Pain or Reflux
Constipation req. Doctor Visit
Bladder or Kidney Infections
Other Urologic Problems
Bedwetting (After 5 Years Old)
Eye Conditions Glasses / Contacts
Problem with Hearing
Chronic or Recurrent Skin Problems (Acne or Eczema)
Anemia or Bleeding Problems
Blood Transfusions
Frequent Headaches
Seizures/Neurological Disorders
Developmental Delays Learning Disabilities
ADD or ADHD
Mental Health Concerns
Orthopedic Problems
Diabetes
Thyroid or other Endocrine Issues
Child is a Female (Date Period Started)
Any other Female Problems with Periods
Use of Alcohol or Drugs
Smoking
Emotional Problems
Other Significant Problems

	Child's Mother	Child's Father	Sibling	Grandmother	Grandfather	Uncle	Aunt	Other
Seasonal Allergies
Eczema/Dry Skin
Asthma/Lung Disease
Heart Disease or Condition
High Blood Pressure
High Cholesterol
Diabetes/Other Endocrine Problems
Cancer
Anemia
Bleeding Disorders
Epilepsy or Seizures
Developmental Delays
Mental Retardation
Neurological Disorders
ADHD or ADD
Liver Disease
GI Disease
Kidney Disease
Bed Wetting after 10 Years Old
Hearing Impairment
Vision Impairment
Immune Problem, Recurrent Infections
Alcohol Abuse
Drug Abuse
Mental Illness
Tuberculosis
Other Pertinent Conditions

Patient History