Patient Health History Form - PEDIATRICS
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Date
-
Month
-
Day
Year
Date
Reason for Visit
Father's Name
Occupation
Mother's Name
Occupation
PAST MEDICAL HISTORY: Check all that apply (add dates)
Select if Yes
Dates
Asthma
Attention Deficit
Anxiety
Depression
Headaches
Skin Problems
Stomach Problems
Any other health issues:
SOCIAL HISTORY:
Child Lives with?
Are Parents Married?
Yes
No
Siblings?
What school does child attend?
What does child do for exercise?
Is there smoking in the house?
Yes
No
GYN INFORMATION:
(for females only)
Last Menstrual Period
Age of first Period
PAST SURGICAL HISTORY:
What type of surgery and year.
VACCINES:
Do you vaccinate?
Yes
No
What state was child vaccinated in?
Did you use delayed schedule?
Yes
No
Current Medications
Name
Dosage
Frequency
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
ALLERGIES: (Write allergy & reaction)
Latex Allergy
Yes
No
Iodine Allergy
Yes
No
Eggs Allergy
Yes
No
Allergies
None
FAMILY MEDICAL HISTORY
Mark M for Mother, F for Father, S for Sister, B for Brother, A for Aunt, U for Uncle, PGF for Paternal Grandfather, PGM for Paternal Grandmother, MGF for Maternal Grandfather, MGM for Maternal Grandmother. Add Ages if possible.
Type a question
Which Family
Member/Members
Age (if known)
Blood Clots
Diabetes
Drug or Alcohol Abuse
Heart Attack
High Blood Pressure
High Cholesterol
Osteoporosis
Stroke
Thyroid Disease
Cancer
If yes to a family history of cancer, please specify what type/types.
Other Family Medical History:
Back
Next
Name
DOB
REVIEW OF SYSTEMS
Please circle any symptoms that have troubled the child during the last several weeks.
General
Fatigue
Difficulty sleeping
Abnormally high or low energy
Unexplained weight loss
Unexplained weight gain
Generally not feeling well
Any abnormal bleeing
Eyes
Vision Problems
Change in Vision
Eye Pain
ENT
Nasal Discharge
Sinus Congestion
Teeth/gum problems
Cardiovascular
Chest Pain
Heart Palpitations/Flutters
Swelling in Feet
Respiratory
Cough
Shortness of Breath
GI
Nausea
Diarrhea
Black/Tarry Stools
Vomiting
Constipation
Abdominal Pain
Heartburn
Appetite Change
GU
Blood in Urine
Painful urination
Skin/Breast
Skin Rashes
New Skin Lesions
Breast Pain/Concerns
Neurologic
Headaches
Fainting
Difficulty Focusing
Seizures
Stroke Symptoms
Tremor
Numbness
Memory Problems
Other
M-S
Muscle Aches
Joint Aches
Weakness
Endocrine
Heat Intolerance
Hair Loss
Cold Intolerance
Night Sweats
Hot Flashes
Other
Psychiatric
Depression
Anxiety
Suicidal Thoughts
Hallucinations
Insomnia
Other
Heme/Lymph
Easy Bruising/Bleeding
Enlarged Lymph Nodes
Immune/Allergy
Seasonal Allergies
Frequent Illness
Check here if none of the above apply or no changes since last visit
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