New Pediatric Patient Health History

Date

Name*

Date of Birth*

Date

Height

Weight

Preferred Pharmacy*

Pediatrician*

Parent/Guardian Names*

Email*

example@example.com

Race

Preferred Language*

Ethnicity

HispanicNon HispanicOther

Please list family members that are patients or have been seen in our office

Please answer the following the best you can. Some of these may be difficult to answer and the medical staff will assist you when you are brought to the exam room. Anything left blank will be assumed normal / not present.

What is the reason for today's visit?*

Does your child have a history of hearing loss or difficulty?

YesNo

Where is the location of the problem?

How often does it occur? How long does it occur?

Is it painful? If so, please explain:

Is it getting worse, improving or staying the same?

What are some things that make it better or worse?

Other symptoms:

Medication 1

Dose

How Often?

Medication 2

Dose

How Often?

Medication 3

Dose

How Often?

Medication 4

Dose

How Often?

Medication 5

Dose

How Often?

Penicillin Allergy?

YesNo

Penicillin Allergy Reaction?

Environmental Allergies?

YesNo

If yes, please explain?

Medication

SIde effects / Reaction

Medication

SIde effects / Reaction

Medication

SIde effects / Reaction

Medication

SIde effects / Reaction

Medication

SIde effects / Reaction

Was your child a product of a normal pregnancy and delivery?*

YesNo

If no, please explain

Is your child in a daycare setting?*

YesNo

Additional comments / explanation?

Does any family member smoke in the household or car?*

YesNo

Additional comments / explanation?

Are you childs immunizations up to date?*

YesNo

Additional comments / explanation?

1.

2.

3.

4.

Diabetes

YesNo

Relationship

Explanation:

High Blood Pressure

YesNo

Relationship

Explanation:

Heart Disease

YesNo

Relationship

Explanation:

Cancer

YesNo

Relationship

Explanation:

Hearing Loss

YesNo

Relationship

Explanation:

Asthma

YesNo

Relationship

Explanation:

Stroke

YesNo

Relationship

Explanation:

Respiratory Failure

YesNo

Relationship

Explanation:

Bleeding Disorder

YesNo

Relationship

Explanation:

Anesthetic Complications

YesNo

Relationship

Explanation:

Other Inherited Diseases

YesNo

Relationship

Explanation:

Anesthetic Complications*

YesNo

Explain

Eye Penetrating Injury Involving Metal*

YesNo

Explain

Claustrophobia*

YesNo

Explain

Bleeding Problems*

YesNo

Explain

Cancer*

YesNo

Explain

Skin Changes*

YesNo

Explain

Ear, Nose, Throat Problems (unrelated to today's visit)*

YesNo

Explain

History of Fever,Weight Loss or Chills*

YesNo

Explain

Visual Changes*

YesNo

Explain

Hearing Problems or Ringing in the Ears*

YesNo

Explain

Dizziness / Vertigo*

YesNo

Explain

History of Noise Exposure*

YesNo

Explain

Are you Pregnant (women only)*

YesNo

Explain

Cardiovascular Problems (ex: Heart attack, chest pain)*

YesNo

Explain

Respiratory Problems (ex: Asthma, wheezing)*

YesNo

Explain

Gastrointestinal Problems (Bloody stools, ulcers)*

YesNo

Explain

Genitourinary Problems (ex: Painful, bloody urination)*

YesNo

Explain

Musculoskeletal problem: (ex: Arthritis)*

YesNo

Explain

Neurological Problems (ex: Stroke, seizure)*

YesNo

Explain

Psychiatric Problems (ex: Depression, anxiety)*

YesNo

Explain

Endocrine Problems (ex: Diabetes, low thyroid)*

YesNo

Explain

Immune Problems (ex: AIDS, immune deficiencies)*

YesNo

Explain

Signature

Clear

New Pediatric Patient Health History

Medications

Allergies / Sensitivities

Other Medication Allergies

Birth / Social History

Past Surgical / Major Illness History

Family History

Patient Medical History