Pediatric History Form

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PATIENT NAME ____________________________________________
D.O.B. ________________________________________________________
PEDIATRIC HISTORY FORM
When was your child’s last physical exam? __________________________________________________________________________
Where? __________________________________________________________________________________________________________________
BIRTH HISTORY
Yes
No
☐☐Did you receive prenatal care? Where?
Started care at ____________ month.
☐☐Was the baby full term? Birth weight?
Vaginal Delivery
☐ Why? _________________________________________________________
☐C-section
☐☐Did the baby go home with you from the hospital? If no, why not?
Hospital where the baby was born: _______________________________________________________________________
MEDICAL HISTORY
Yes
No
☐☐Has your child ever been hospitalized overnight or had any previous surgeries?
If yes, when, where, why? _________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
☐☐Is your child followed by a specialist
If so, for what condition? __________________________________________________________________________________
☐☐Does your child take any medications on a regular basis, including vitamins?
Please list: __________________________________________________________________________________________________
☐☐Is your child allergic to any medication? _________________________________________________________________
What happens when your child takes this medicine? ___________________________________________________
☐☐Are your child’s shots up to date?
☐☐Has your child ever had a reaction to an immunization?
What happened? ___________________________________________________________________________________________
☐☐Does your child have any food allergies? _________________________________________________________________
What happens? _____________________________________________________________________________________________
☐☐Has your child ever had a positive TB test?
When? _______________________________ Did he/she receive a chest x-ray? _________________________________
☐☐Has your child ever had any blood work or special tests done?
☐☐Has your child ever had:
UTI?
Date: ______/______/______
Medicine taken: ____________________________________
Asthma/Wheezing? Date: ______/______/______
Medicine taken: ____________________________________
☐☐Does your child have frequent ear infections?
☐☐Does your child have any medical problems? (Such as asthma, seasonal allergies,
eczema, ADHD, seizures, etc.) _____________________________________________________________________________
FOR FEMALE PATIENT’S ONLY
Yes
No
☐☐Have you started your periods? What age? ______________________________________________________________
☐☐Are they regular? They last __________ days
LMP: ______/______/______
☐☐Cramps? Treatment for cramps ___________________________________________________________________________
Comments: _____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________

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