Pediatric History Form Page 2
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1
2FAMILY MEDICAL HISTORY
Has anyone in your child’s family had any
of these conditions?
1.
Alcohol Abuse
2.
Anemia (V18.2)
3.
Asthma (V17.5)
4.
Autistic Disorder
5.
Born with Congenital Abnormalities
6.
Cancer
7.
Cystic Fibrosis (V18.19)
8.
Delayed Developmental Milestones
9.
Depression
10.
Diabetes Mellitus (V18.0)
11.
Drug Dependence
12.
Eczema
13.
Heart Disease (V17.49)
14.
Hepatitis
15.
Hypercholesterolemia
16.
Hypertension (V17.49)
17.
Juvenile Rheumatoid Arthritis/
Autoimmune issues
18.
Migraine Headache
19.
No Significant Family History
20.
Reported family history of Allergies
21.
Reported family history of Bleeding
Problems
22.
Reported family history of Deafness
before age 5
23.
Reported family history of Early Sudden
Deaths
24.
Reported family history of Kidney Disease
25.
Reported family history of Mental
Illness (not retardation)
26.
Seizure Disorder (V17.2)
27.
Sudden Infant Death Syndrome
28.
Thyroid Disorder (V18.19)
29.
Tuberculosis
30.
Gastrointestinal Issues (such as IBD)
SOCIAL HISTORY
☐Foster Child
☐Adopted
Composition of Household – Brothers:
Name Child 1: _______________________________________________________________ DOB: _____________________ Age: ____________
Name Child 2: _______________________________________________________________ DOB: _____________________ Age: ____________
Composition of Household – Sisters:
Name Child 1: _______________________________________________________________ DOB: _____________________ Age: ____________
Name Child 2: _______________________________________________________________ DOB: _____________________ Age: ____________
Guns in Home? ☐Yes
☐No
Guardians are: ☐Currently Married ☐Divorced ☐Never Married ☐Separated ☐Single ☐Other
Guardian’s Occupation: ___________________________________ Guardian’s Occupation: ____________________________________
Guardian’s Signature ______________________________________________________________________ Date: ______/______/______
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Parent category: Medical