KIDS DOC PEDIATRICS

Child’s Name: ______DOB: ______

PREGNANCY & BIRTH

Birth Weight: ______Length: ______

Delivery: Vaginal C-Section

Mother treated for infectionYN

Infant treated for infectionYN

Any antibiotics given to motherYN

Any antibiotics given to infantYN

JaundiceYN

Low birth weightYN

Any trouble at birthYN

PrematurityYN

Explain any yes answers:______

______

NUTRITIONAL ASSESSMENT

a. Newborn:Formula: ______Breast: ______

If formula, which one? : ______How many ounces? : ______

How often does the baby eat? : ______

b. Infants:Have you started cereal? Y N

Have you started juices? YN

Have you started solids?YN

c. Toddlers:Any food allergies?YN

Other concerns: ______

______

  1. All Patients:Are there any concerns/questions regarding feeding/eating habits?

______

DENTAL

If your child is over three years, have they seen a dentist:YN

Does your child brush his/her teeth YN

Is there fluoride in your water supply?YN

VISION/HEARING

Any concerns with your child’s vision or hearing?YN

Has your child been evaluated by any eye doctor?YN

DEVELOPMENT

Do you have any concerns with your child’s growth or development? YN

Have you been told your child is developmentally delayed? YN

PAST MEDICAL HISTORY

Family History(Please include parents, siblings, and grandparents)

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DIABETES ______

HEART DISEASE ______

HIGH BLOOD PRESSURE______

CANCER______

ASTHMA______

ANEMIA______

TUBERCULOSIS______

SICKLE CELL ANEMIA______

LEUKEMIA______

SEIZURES______

DEATH IN THE 1ST YEAR OF LIFE____

THYROID DISORDERS______

BEHAVIOR/DEVELOPMENTAL______

ADD/ADHD______

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AIDS/HIV ______STROKES ______

KIDNEY DISEASE ______ARTHRITIS ______

MENTAL DISORDER______

OTHER ______

Child’s History (Please circle any medical conditions your child may have)

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DIABETES

ALLERGIES

ASTHMA

HIGH BLOOD PRESSURE

CANCER

EPILESY

TUBERCULOSIS

HEART PROBLEMS

SICKLE CELL ANEMIA

SICKLE CELL DISEASE

LEUKEMIA

SCHOOL PROBLEMS

HIV/AIDS

STD’S

BEHAVIORAL PROBLEMS

ADD/ADHD

DEVELOPMENTAL PROBLEMS

KIDNEY DISEASE

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MENTAL DISORDER

OTHER: ______

Please list any Hospitalizations: ______

______

Please list all Surgical Procedures your child has had (Year and Procedure)

______

______

______

Allergies to Medications ______

Allergies to Food ______

Patient’s Habits and Social History

HAS THIS CHILD BEEN EXPOSED TO: (Please circle one)

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SMOKINGYN

ALCOHOL/DRUGSYN

CAFFEINEYN

GUNSYN

PHYSICAL ABUSEYN

MENTAL ABUSE YN

SEXUAL ABUSEYN

TUBERCULOSIS YN

HIV/AIDSYN

OTHER: ______

______

ANY OTHER ISSUES YOU WOULD LIKE TO DISCUSS WITH THE PRACTITIONER? ______

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School/ Daycare: ______Grade: ______

Review of Systems

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FEVERYN

SORE THROATS YN

HEARING LOSS YN

DECREASED VISIONYN

PALPITATIONSYN

ABDOMINAL PAIN YN

DIARRHEAYN

CHEST PAIN YN

HERNIA YN

INCREASED THIRSTYN

CONVULSIONS/SEIZURESYN

BACK PAINYN

DEPRESSION YN

ANXIETYYN

EXCESSIVE URINATIONYN

WEIGHT LOSS YN

HEADACHEYN

BLURRED VISION YN

COUGH YN

HEART TROUBLE YN

N/V YN

RECTAL BLEEDING YN

DECREASED APPETITEYN

TESTICLE PAIN/MASSESYN

ANEMIA YN

PAINFUL URINATION YN

STD’S YN

BIRTH CONTROLYN

PAIN YN

OTHER ______

______

______

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By signing below you agree that the above information is correct to the best of your knowledge.

______

PARENT’S SIGNATURE DATE

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