Patient History Form
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2Hand In Hand Pediatrics
Patient History Form
Welcome to Hand In Hand Pediatrics! Please fill out this form as much as possible.
Patient Name ___________________________________________________________ Birth Date _________________
Person completing this form _______________________________________________ Relationship _______________
Birth History
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Is the child yours by:
birth
adoption
stepchild
other
Gestational age at birth __________________
Birth weight __________________
Birth Length ______________
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Birth Hospital ___________________________________
Hepatitis B vaccine? Yes
No
Date _______________
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Apgars score __________
Newborn hearing screen
pass
not pass
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Delivered by
vaginal
c-section
Reason for c-section __________________________________________
Complications during newborn hospitalization ____________________________________________________________
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Family History
Please check all categories that apply and which family member has had the diagnosis. Please include parents,
grandparents, siblings, and parents’ brothers and sisters. Please mark all that apply.
Biological
Biological
Condition
None
Mother
Father
Sibling
Grandparent
Other
Asthma
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Anemia
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Allergies
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Bleeding/Clotting
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Disorder ___________________________________
Cancer
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Type ______________________________________
Diabetes
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Depression
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Gastrointestinal
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Headaches
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Heart Attack <50 yrs
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Heart disease
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High blood pressure
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High cholesterol
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Psychological
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ADHD, autism, anxiety ____________________________________
Seizures
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Stroke
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Thyroid disease
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Tuberculosis
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Please explain all positives ____________________________________________________________________________
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Parent category: Medical