Pediatrics Medical History Form printable pdf download

Pediatrics

Seen by:______

Reviewed by:_______

Patient Name: _____________________________________

M/F

Date of Birth: ______________

Parent Names: ___________________

Siblings & DOB: _________________________________________________

Significant Past Medical Problems, illnesses or hospitalizations:_____________________________________________

_________________________________________________________________________________________________

Has your child had chicken pox disease:  Yes Date: ______________

 No

Has your child had any of the following operations? If yes, fill in the year of surgery.

Year

Appendix Removed

Tonsils/Adenoids Removed

Ear Tubes

Other operations/procedures: _______________________________________________________________________

_________________________________________________________________________________________________

Active or Chronic Problems (check all that apply for this patient or list below):

 ADD/ADHD

 DDH – hip dysplasia

 Diabetes

 High blood pressure

 Seizures

 Allergies

 Deafness

 Ear Infections

 Mental illness

 Strabismus (lazy eye)

(frequent)

 Asthma

 Depression/Anxiety

 Eczema

 Migraines/Headaches

 Sickle Cell

 Cancer

 Developmental Delay

 Elevated Cholesterol

 Obesity

 Urinary Reflux

 Other (list below)

 Heart Disease

 Scoliosis

 Frequent or Recurrent UTI

Please explain any that apply:

_________________________________________________________________________________________________

Please list other active or chronic problems: ____________________________________________________________

_________________________________________________________________________________________________

Please list other pertinent information we should know, including other doctors and/or specialists your child sees:

_________________________________________________________________________________________________

Patient’s Drug Allergies & reaction: ____________________________________________________________________

Patient’s Food Allergies & reaction: ___________________________________________________________________

Current Medications – Please list all over the counter medications, supplements, herbal medications and/or any

medications prescribed by your PCP or specialist.

Medication

Dosage

Times per Day

Prescribed by

-OVER PLEASE-

Pediatrics Medical History Form

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