7502 State Road Suite 3350 Cincinnati, OH 45255 Phone: (513)231-3345 FAX: (513)231-6739

Child’s Name: / Date of Birth: / Age:
Address: / Form Completed By: / Date:
HOUSEHOLD – please list all those living in the child’s home
Name Relationship to patient Age Health Problems
BIRTH HISTORY

Birth Weight_____lbs. _____oz.Date of Adoption: (if applicable)______

Was patient born at term?____ Early?_____Late?_____Was the delivery □ Vaginal? □ Cesarean?

If early, how many weeks gestation? ______If cesarean, why?______

Did mother have any illness or problems during pregnancy? Did baby have any problems right after birth? □ No □ Yes

□ No □ Yes Explain: ______Explain: ______

During pregnancy did mother smoke cigarettes? □ No □ Yes Was initial feeding □ Breast? How long?_____ □ Formula?

Drink Alcohol? □ No □ Yes How long?______Did baby go home with mother from hospital? □ Yes □ No

Use drugs or medications □ No □ Yes What?______Explain:______

How long?______

DEVELOPMENTAL HISTORY

Name of school (or daycare) and grade ______

How is his/her behavior at school? ______

Has he/she repeated a grade? If yes, what grade? ______

How is he/she doing academically? ______

Is he/she in any special, resource, or gifted classes? ______

Does he/she have an IEP or 504 plan? ______

How many hours does he/she sleep at night?______Naps (number and length) ______

Are you concerned about your child’s physical development? ______

Are you concerned about your child’s mental/ emotional development? ______

Does you child have any feeding/ dietary problems? ______

SOCIAL HISTORY

Are there any concerns for lead exposure? (old home/ old plumbing/ peeling paint) □ No □ Yes

Are there smoke detectors at home? □ No □ YesAre there carbon monoxide detectors at home? □ No □ Yes

What is your water source? ______Is there a swimming pool at home? □ No □ Yes

Are there guns in the home? □ No □ Yes Does he/she wear a bike helmet? □ No □ Yes

Does the child spend time with anyone who smokes (in or out of the home)? □ No □ Yes Who?______

Are there pets at home? □ No □ Yes What/ how many?______Does the child have a tv in his/her room? □ No □ Yes

How may hours of TV per day? ______Computer/ tablet/ cell phone?______Video games?______

Are there any concerns about your child’s relationships? (school/ friend/ family)______

Sports/ Exercise: Type:______How often?______How Long?______

MEDICAL HISTORY

Date of child’s last check-up:______Date of last dental visit:______

Does your child take any medications or vitamins regularly? □ No □ Yes What?______

______

Does your child see any other healthcare providers? □ No □ Yes Who?______

Has your child ever been treated for or diagnosed with:

□ Asthma ______□ Seizures ______

□ Wheezing / bronchiolitis______□ Anemia ______

□ Allergies (any) ______□ Eczema/ skin problems ______

□ Recurrent ear infections______□ Depression/ anxiety ______

□ Pneumonia______□ Heart murmur______

□ Urinary tract infection______□ ADD/ ADHD______

□ Constipation or diarrhea______□ Eye problems______

□ Frequent headaches/ migraines______□ Concussion/ head injury______

□ Other chronic condition______

Has your child ever been hospitalized? □ No □Yes Explain:______

Previous surgeries, dates, and hospital? ______

List any specialists your child has seen, dates, and reasons:______

FAMILY HISTORY

Do any family members have any of the following conditions? Please specify maternal/ paternal relation for extended family.

□ Asthma______□ Seizures______

□ Anemia/ bleeding disorder______□ Allergies______

□ Diabetes______□ Heart disease (before age 55)______

□ High cholesterol______□ High blood pressure (before age 55)______

□ Obesity______□ Cancer (before age 55)______

□ Liver disease______□ Kidney disease______

□ Mental illness/ depression/ anxiety______□ Drug/ alcohol abuse______

□ Autism/ developmental problems______□ Immune disorder______

□ GI problems______□ Thyroid issues______

□ Other Chronic problems______