New Patient Medical History
 
 

Pediatric History Form

Child's Name _____________________________________________________

                                      furst                                       nuddke                                      last

Date of Birth ___________________________    

A. Birth History

1. Birthplace  _____________________________

2. Was pregnancy normal? ________________________________________________

3. Was delivery normal? __________________________________________________

4. Was baby full term? ___________________________________________________

5. Birth weight _________________  6. Birth length ___________________________

7. Any problems in nursery?

8. Breast fed or bottle fed? ________ 9.  Any feeding problems?__________________

B. Growth and Development

1. Ages when first:

Sat _____________ Crawled ___________ Rolled ____________ Walked _________

First Teeth ____________ Toilet Trained ___________

2. School History:

Year in school ___________ Nursery ___________

Grades Averaged ____________ School Name _______________________________

School Problems _______________________________________________________

_____________________________________________________________________

Attends special school or classes? _________________________________________

_____________________________________________________________________

Discipline or behavior problems? __________________________________________

____________________________________________________________________

Ever seen by psychologist, speech therapist or special teachers? _________________

____________________________________________________________________

C. Hospitalizations

(When, Where, Why?)__________________________________________________

____________________________________________________________________

____________________________________________________________________

D. Surgery

(When, Where, Why?) __________________________________________________

____________________________________________________________________

____________________________________________________________________

E. Serious Injuries

(When, Where?) _______________________________________________________

____________________________________________________________________

F. Allertic Reactions

(Drugs, Asthma, Hives, Eczema, Hay Fever, Food) _____________________________

___________________________________________________________________

G. Family History

1. Father: Living? _______  Age now __________ Health ________________________

2. Mother: Living? ______ Age now __________ Health _________________________

3. Brothers/Sisters _________ How Many _______________

    Ages _______________________________________________________________

   Healthy? _____________________________________________________________

4. Any family history of:

   Diabetes ___________________________  Allergies __________________________

  Convulsions ________________________  Heart Disease _______________________

  TB _______________________________  Cancer_____________________________

  Other ________________________________________________________________

H. Past Medical History

1. Any problems with:

  Sleeping ______________________________

  Bedwetting ____________________________

Weight ________________________________

Height _________________________________

Nail Biting ______________________________

Nightmares _____________________________

2. Diet:

  Any colic problems? _________________________________________________

  Use special diets? ___________________________________________________

  Taking vitamins regularly? ____________________________________________

  Taking fluoride? ____________________________________________________

3. Contagious diseases (what age?)

  Measles________  Mumps _________ Rubella (German Measles) _____________

  Chicken pox _________ Scarlet fever __________ Other ____________________

4. Immunizations (please give age and/or dates)

  DPT series _____________ Boosters ___________________________________

  Polio series ____________ Boosters ___________________________________

  Measles, Mumps Rubella ____________________________________________

  TB Test _______________________  Others ____________________________

5. Medications (Does your child take any now?)

  _______________________________________________________________ 

I. Demographics

How long has your family lived in this area? ______________________________

Where did you live before coming to this area? ____________________________

Travel outside the US (When and where) ________________________________

J. General Survey

Has your child had any unusual problems with the following?

Head _________________________ Eyes _____________________________

Ears/Nose/Throat_________________________________________________

Chest/Ribs/Sternum _______________________________________________

Heart ________________________ Lungs ____________________________

Stomach _____________________ Kidneys ___________________________

Bladder _____________________  Skin ______________________________

Bones/Muscle/Joints _____________________________________________

Blood ______________________

When was your child's last blood test? _______________________________

When was your child's last urine test? ________________________________

K. Any Special Comments About Your Child?

______________________________________________________________

______________________________________________________________

L. Your Chid's Last Doctor's Name and Address

______________________________________________________________

______________________________________________________________

Person Completing Form:

Name: _________________________________________

Signature: ______________________________________

Relationship to patient: ____________________________

Date: __________________________________________