Family/Medical History

Who has diabetes in the family?

Who has thyroid disease in the family?

Father’s history: Age Height Weight .

Medical problems:

Onset of Puberty: early average late

Mother’s history: Age Height Weight .

Medical problems:

Age of first menstrual period:

FULL Siblings (does not include half siblings)

1) Name:Age: Height: Weight: .

  1. Male/female
  1. If female, aget at first menstrual period:
  1. Medical problems:

2)Name:Age: Height: Weight: .

  1. Male/female
  1. If female, aget at first menstrual period:
  1. Medical problems:

3)Name:Age: Height: Weight: .

  1. Male/female
  1. If female, aget at first menstrual period:
  1. Medical problems:

4)Name:Age: Height: Weight: .

  1. Male/female
  1. If female, aget at first menstrual period:
  1. Medical problems:

Maternal Grandfather: Height: Weight: .

Maternal Grandmother: Height: Weight: .

Mother’s Siblings: Male/Female Height: Weight: .

Mother’s Siblings: Male/Female Height: Weight: .

Mother’s Siblings: Male/Female Height: Weight: .

Mother’s Siblings: Male/Female Height: Weight: .

Paternal Grandfather: Height: Weight: .

Paternal Grandmother: Height: Weight: .

Father’s Siblings: Male/Female Height: Weight: .

Father’s Siblings: Male/Female Height: Weight: .

Father’s Siblings: Male/Female Height: Weight: .

Father’s Siblings: Male/Female Height: Weight: .

Is anyone taller than 6 feet 7 inches or shorter than 4 feet 11 inches on either Mother or Father’s side of the family? If yes, on which side (circle one): Mother/Father

Who lives at home with the patient?

Mother’s Occupation:

Father’s Occupation:

Special family circumstances (ie divorce):

Mother’s Perinatal History

Weight gain during pregnancy: lbs

Bleeding: Yes/No

Infection: Yes/No

Use of drugs during pregnancy: Yes/No

Use of tobacco during pregnancy: Yes/No

Use of alcohol during pregnancy: Yes/No

Hormone use during pregnancy: Yes/No

Labor/Delivery complications: Yes/No

If so, what complications?

Birth History

Gestational age: weeks

Patient’s birth weight? lb oz

Patient’s birth length? inches

Jaundice (yellow skin) present at birth? Yes/No

Complications after birth? Yes/No

Past Medical History

Infant/toddler feeding problems? Yes/No

Immunizations up to date? Yes/No

Past hospitalizations/surgeries? Yes/No

If yes, what kind of surgery and when?

Trauma (car accidents, broken bones, other serious injury)? Yes/No

If yes, what kind of trauma and when?

Growth/Development Milestones

Teeth erupted? Yes/No (If yes, indicate what age teeth first appeared: )

Patient walking? Yes/No (If yes, how old when first started walking? )

Language Development (circle one): early average late

Potty trained? Yes/No (If yes, at what age? )

What grade is your child in school?

What kind of grades does your child receive?

Has attendance been normal, or does your child miss a lot of school?