Pediatric Medical History Form
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1
2Pediatric Medical History Form
Your answers on this form will help your provider understand your child’s medical history.
CHILD’S NAME:__________________________
DATE OF BIRTH:__________________________
PERSON COMPLETING FORM/RELATIONSHIP_____________________________________________
DATE OF FORM COMPLETION_____________________
MEDICATIONS:
Medication
Dose
How many times a day
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
MEDICATION ALLERGIES: □ No
□ Yes
If yes, to what medication(s) and what was the reaction_____________________________________________
IMMUNIZATION HISTORY:
To the best of my knowledge, my child is up to date on his/her immunizations □ No
□ Yes
If no, why?________________________________________________________________________________________
BIRTH HISTORY:
Please indicate any medical problems during pregnancy ____________________________________________________
Please list any medications taken during the pregnancy_____________________________________________________
Any drug or alcohol use during the pregnancy □No
□ Yes ______________________________________________
Delivered by
□ elective C-section
□ emergent C-section
□ forceps
□ vacuum extraction
□ normal vaginal delivery
If not a normal vaginal delivery, why?__________________________________________________________________
Number of weeks gestation___________
Birth weight_______________ APGAR scores: 1 minute______ 5 minute______ Discharge weight_______________
Did the baby receive the Hepatitis B vaccine □ No
□ Yes
If yes, date given ________________________
Please indicate any medical problems during the newborn period_____________________________________________
Name of hospital where infant was born_________________________________________________________________
PERSONAL MEDICAL HISTORY:
Please check if your child has had any of the following medical problems:
□ ADD/ADHD
□ Chicken pox
□ Headaches
□ Liver disease/Hepatitis
□ Allergies
□ Concussion
□ Hearing problems
□ Recurrent ear infections
□ Anemia
□ Diabetes
□ Heart murmur
□ Seizures
□ Asthma
□ Eczema
□ Congenital heart disease
□ Urinary Tract Infections
□ Bleeding disorder
□ Fracture
□ High blood pressure
□ Vesicoureteral reflux
□ Bronchiolitis
□ Handicaps/Disabilities
□ Kidney disease
□ Vision problems
HOSPITALIZATIONS:
Has your child every stayed overnight in a hospital?
□ No
□ Yes
If yes, when and why?_______________________________________________________________________________
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