Patient Health History Form
Patient's Name
First Name
Middle Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Today's Date
-
Day
-
Month
Year
Date
Name of person completing this form
Relationship to Patient
Name of child's previous pediatrician:
Delivery and Birth History
Unknown
Was your child adopted?
No
Yes
Date of Adoption
-
Month
-
Day
Year
Date
Place of Birth
Name of Hospital/Home
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Delivery
Vaginal
Caesarean
If vaginal, breech/feet first?
If caesarean, was it planned?
If known, how old was the birth mother at time of delivery?
Was the child premature?
No
Yes
Days
Weeks
Child's birth weight
Birth length
Head Circumference
Were there any significant medical problems during your pregnancy?
Yes
No
Were there any significant complications during labor or the baby's newborn period
Yes
No
If yes, to any of the above, please explain:
Growth and Development
Have you or your prior pediatrician ever had any concerns about your child's growth or development? ( speech/language, social skills, motor skills, etc. )
Yes
No
Please provide your child's age when they first:
Sat up without help:
Age
Crawled:
Age
Walked without help:
Age
Spoke his/her first words:
Age
Slept through the night:
Age
Girls Only: Age at first period:
Age
Please indicate any developmental concerns or issues you would like to speak to the provider about:
Child's Medical History
Please check if your child has had any of the following conditions:
Been hospitalized overnight
Used a nebulizer
Broken Bones
Mental/Behavior Challenges
Pneumonia
Liver Disease/Hepatitis
Bladder Infection
Skin Problems
Eating Disorder/Anorexia or Bulimia
Learning Delay
ADD
Obesity/Overweight
Asthma/wheezing
Surgery
Frequent or severe sprains
Seen in the Emergency Room
Seizure/Epilepsy
Kidney Disease
Sexual Transmitted Disease
Hearing Problems
Seasonal Allergies
Learning Disability
Lead Poisoning
Emotional/Behavioral Challenges
If you checked any of the above, please describe
Medications and Allergies
Please list current medications, vitamins, and supplements, even those used intermittently:
Please list allergies or reactions to medications, vaccines or foods
Allergy
Reaction
1
2
3
4
5
Social History
Please list all those living in the child's household:
Name
Age
Relationship
1
2
3
4
5
Does your child attend school?
Yes
No
Does your child attend school?
Yes
No
Daycare?
Yes
No
Have a FT Nanny?
Yes
No
Does your child attend aftercare?
Yes
No
Does your child attend summer camp?
Yes
No
Do you have pets in the home?
Yes
No
If yes, type and number of pets
Parents working outside of the home
Yes
No
What language(s) are spoken at home:
Approximately how many hours a day does your child spend in front of a screen?
Does your child exercise/play sports?
Yes
No
If yes, when, where and how long?
Has your child or anyone in your household traveled internationally in the past 5 years?
Yes
No
If yes, who/m and to where?
Family History
Please indicate family members who have had any of the following conditions
Mom
Dad
Sister
Brother
Mom's Mom
Mom's Dad
Dad's Mom
Dad's Dad
Mom's Sister
Mom's Brother
Dad's Sister
Dad's Brother
Alcoholism
Anemia
Asthma/wheezing
Cystic Fibrosis
TB / Lung Disease
Autism
Autoimmune Disorder
Birth Defect/Congenital Anomaly
Bleeding Problem
Blood Disorder
Sickle Cell
Anemia
Thalassemia
Depression
Diabetes
Eczema (Atopic Dermatitis)
Food Allergy
Genetic Disorder
Hearing Disorder
Heart Disease
Sudden Cardiac Death
Heart Attack
High Blood Pressure
High Cholesterol
Immune Disorder
Inflammatory Bowel Disease
Kidney Disease
Mental Retardation
Learning Disability
Migraine Headaches
Psychiatric/Mental Illness
Scoliosis
Seizure Disorder
Stroke
Substance Abuse
Thyroid Disorder
Tobacco Use
Tuberculosis
Death before Age 56
Submit
Should be Empty: