Fillable Pediatric New Patient History Form printable pdf download

OFFICE USE ONLY

MOUNT CARMEL

MRN: ________________

Medical Group

PEDIATRIC NEW PATIENT HISTORY FORM

Welcome to our practice! We ask that you fill out this form (both pages) and complete all areas to the best of your

knowledge. This will help us get to know you and your child better and target any issues or concerns you may have.

Child’s Name:________________________________________ Birth Date:_______________ Date: ______________

Birth Hospital: ________________________ (City: _____________________________)

Mother’s name:_________________________________ Birth Date:____________ Occupation: ____________________

Father’s name: _________________________________ Birth Date:____________ Occupation: ____________________

Are parents? (circle all that apply)

Married

Single

Separated

Divorced

Living together

Who does child live with? ______________________________________________________________________

Name of guardian (if applicable): __________________________________ Relationship to child: __________________

Names of brothers and sisters: ________________________________________________________________________

Please list any other members of the household:__________________________________________________________

Was your child adopted?

Yes No

If yes, at what age? ________

From what country/city? ____________________

Religious preference (optional): ______________________________________________________________________

Mom’s Pregnancy History:

Number of pregnancies before this child (including miscarriages): ________

How long was this pregnancy? (# of weeks): ________________

How many months pregnant was mom when prenatal care was started for this child? __________

Please list any illnesses mom experienced during this pregnancy (such as high blood pressure, diabetes, thyroid

problems): ________________________________________________________________________________________

________________________________________________________________________________________________

Please list any medications mom took during pregnancy: __________________________________________________

Did mom smoke during pregnancy? Yes No

Any alcohol consumption? Yes No

Any drug use? Yes No

Patient’s Birth History:

How long was labor (in hours)? _________

Was labor induced? Yes No If yes, why? ______________________

At the time of delivery: (please circle all that apply)

Breech presentation

C-section

VBAC

Breathing problems

Vacuum

Forceps

In the nursery: (please circle all that apply)

Neonatal ICU admission

Antibiotics

Lights for jaundice

Blood transfusion

Oxygen needed

Birth weight: _____________________ Birth length: ___________________ Discharge weight: ____________________

Apgars (if known): ____________________

Length of time in the hospital: ______________

Newborn screen done in hospital? Yes No

Hepatitis B vaccine given in the nursery? Yes No

Please describe any other problems: __________________________________________________________________

________________________________________________________________________________________________

Nutrition History:

Breast fed? Yes No

Duration: ______________

Formula fed? Yes No

Type of Formula: ______________________________ Duration: _______________________

At what age did your child start solid foods? ____________ Does your child use a pacifier? Yes No

Is your child taking vitamins? Yes No

Is your child using a fluoride supplement? Yes No

Any feeding problems? (circle all that apply)

Vomiting or reflux

Colic

Diarrhea

Food allergies (please list): ______________________________________

IMMUNIZATIONS: PLEASE PROVIDE US WITH AN UPDATED LIST OF YOUR CHILD’S IMMUNIZATIONS

Pediatric New Patient History Form

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