Patient History Form Page 2
ADVERTISEMENT
1
2Patient Name ___________________________________________________________ Birth Date _________________
Past Medical History
Has our child ever been treated or diagnosed with: (explain)
Yes
No
□
□
Asthma/wheezing/pneumonia
____________________________________________________
□
□
Allergies- food/pets/seasonal
____________________________________________________
□
□
Anemia/blood disorder
____________________________________________________
□
□
Diabetes
____________________________________________________
□
□
Ear infections/strep throat
____________________________________________________
□
□
Genetic disorder
____________________________________________________
□
□
Heart disease/defects
____________________________________________________
□
□
Intestinal problems
____________________________________________________
□
□
Neurological (headaches/seizures)
____________________________________________________
□
□
Psychological (ADHD, autism, anxiety)
____________________________________________________
□
□
Urinary tract infections/disorders
____________________________________________________
□
□
Other chronic conditions
____________________________________________________
□
□
Has your child ever been hospitalized overnight?
Yes
No
Please explain and give dates _______________
__________________________________________________________________________________________________
Please list any specialist(s) your child is seeing ____________________________________________________________
__________________________________________________________________________________________________
Medications
Allergies to medications and reactions ___________________________________________________________________
Current medications and dose _________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Vitamins, herbal supplements, over the counter medications_________________________________________________
__________________________________________________________________________________________________
Surgical History
Type of surgery and date of surgery _____________________________________________________________________
Social History
□
□
□
□
Who lives in the household with your child?
Parent
Parent
Siblings
#_____
Other
□
□
□
□
Parent(s)
Married
Single
Divorced
Remarried
Name of Step-parent ___________________________
□
Custody
(Please bring in custody papers if other than shared)
Smokers Yes No
Pets Yes No
What kind?_____________________
Age of home ________
Does your child stay home with you?
Yes No
Does your child attend daycare/preschool/babysitter? Yes No
Developmental
At what age did your child: roll over __________
crawl ___________ walk __________
speak 2 words _________
Present grade in school _______________
_____________________________
_____________________________
Reviewed by
Physician
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical