Pediatric Health History Form

Child’s Name______Date of Birth______

Mother’s Name______MaleFemale (circle one)

Father’s Name______

Allergies tomedication/foodMedications

______

______

______

Medical History

Please check the box if your child has had any of the following:

  • Anemia
  • Asthma
  • Bronchitis
  • Chicken Pox
  • Hepatitis
  • Measles
  • Rheumatic fever
  • Whooping cough

General

  • Chills
  • Depression
  • Dizziness
  • Fainting
  • Forgetfulness
  • Headache
  • Loss of sleep
  • Mood Swings
  • Nervousness
  • Numbness
  • Sweating
  • Tiredness
  • Weight loss/gain

Cardiovascular

  • Chronic/Recurrent
  • Breathing Problem
  • Chest Pain
  • Irregular heart beat

Eyes

  • Crossed/Wandering eye
  • Eye irritation
  • Headaches
  • Vision problems

Hearing/speech

  • Difficulty hearing
  • Earache
  • Ear infections
  • Hoarseness
  • Speech Problems
  • Bleeding Gums
  • Grinding teeth
  • Thumb sucking
  • Last dental check-up
  • Poor appetite
  • Bloody/Dark stools
  • Constipation
  • Diarrhea
  • Excessive hunger/thirst
  • Nausea
  • Rectal bleeding
  • Reflux
  • Stomachaches
  • Vomiting

Genito-Urinary

  • Bed-wetting
  • Blood in urine
  • Frequent urination
  • Painful urination
  • Discharge from Vagina/penis

Musculoskeletal

  • Broken bones/sprains
  • Coordination problems
  • Posture Problem

Nose/Throat/Chest

  • Difficulty Breathing
  • Difficulty Swallowing
  • Frequent colds
  • Hoarseness
  • Mouth Breathing
  • Nosebleeds
  • Persistent Cold
  • Sinus Problems
  • Snoring
  • Sore throats
  • Strep Throat
  • Tonsil infections
  • Wheezing

Skin

  • Acne
  • Bruise easily
  • Change in moles
  • Hives
  • Itching/Rash
  • Scars
  • Sores that don’t heal

Prenatal and Infant Health History

Place of Birth______

During Pregnancy did mother have any of the following? Check all that apply

  • Alcohol Use
  • Tobacco Use
  • Drug Use
  • Diabetes
  • Fever
  • High Blood Pressure
  • Sexually Transmitted Disease
  • Other Illnesses______
  • Medications used during pregnancy______

Birth Weight______Birth Length ______

Mother’s age at time of birth______

Feeding

  • Breast fed
  • Bottle Fed

Delivery (check all that apply)

  • On Time
  • Premature
  • Late
  • Vaginal Delivery
  • C-section
  • Induced
  • Prolonged
  • Breech

Infant Health Problems

  • Birth defects
  • Infection
  • Transfusion
  • Breathing Problems
  • Jaundice

Developmental- Please note age at which your child:

Walked______Rolled over______Crawled______

First Word______Dressed self______Drank from cup______

Toilet trained______

Educational and Social History

Please explain any problems you have about your child in any of the following areas:

Appearance/Weight/Height______

Behavior______

Grades/learning ability______

Sexuality______

Friends______

How many hours per day does your child watch television, surf the internet (not counting homework time) or play video games______

Hours per day of exercise______

Hours per day of extracurricular activities______

Do you suspect that your child is involved with

  • Drugs
  • Alcohol
  • Tobacco

Have you noticed any of the following warning signs of drug abuse:

  • Angry behavior
  • Changes in attitude
  • Depression
  • Skipping school
  • Changes in appearance
  • Changes in friendships
  • Signs of drugs in the house
  • Withdrawal from family and/or friends

Parent Concerns

Please explain any other concerns or questions you have about your child

______

I have answered the questions on this form to the best of my knowledge. I understand that to provide incorrect or incomplete information about my child’s health and symptoms could place my child’s health at risk.

Parent/Guardian Signiature______Date______

Physician comments ______