bamapeds.com - Medical History Form

Medical History Form

Bama Pediatrics
Bama Pediatrics and Allergy 2701 20th Ave, Northport, AL 35476 | Ph (205)333-5900 | Fax: (205)333-6090
Name:
Age:
SEX:
DOB:

MonthDayYear
Date
Chart #:
Date:

MonthDayYear
Date
MOTHER’S HISTORY
Any complications during pregnancy?

YesNo
Pregnancy complication
Name of medication taken during pregnancy:
BIRTH HISTORY
Baby was born on time:
or Early
Birth Weight
APGAR Scores if known
PAST MEDICAL HISTORY
PAST HOSPITALIZATIONS
FAMILY HISTORY
Father
Age
Lives at home:

YesNo
List medical problems if any
Mother
Age
Lives at home:

YesNo
List medical problems if any

Sibling

ALLERGIES
List all known allergies (Medicines and foods) if any
SOCIAL HISTORY
Child lives with:

Mother & DadMomDadGrand ParentsAdoptive/Foster Parents
Live in what kind of house:

HouseApartment
Type of water used:

City WaterWell Water
Child Stays homeAttends day care center/pre-schoolSchool
Mother's Name:
Occupation:
Highest education
Father's Name:
Occupation:
Highest education
Anybody smokes at home?

YesNo
Do you have any pets?

YesNo
DEVELOPMENTAL HISTORY
New Born Baby

YesNo
Child attained all mile stones

On timeDelayedAttends regular schoolSpecial Education

Mile stones ( Birth—1 year)

Mile stones (Age 1—Onwards)

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Signature of Patient or Representative:*

Clear
Date:

MonthDayYear
Date
If not Self, Relationship to Patient
Should be Empty:

Medical History Form