Pediatric History Form

ADVERTISEMENT

Pediatric History Form
Date_______________________
Referred By_______________________________________
Patient Name________________________________________Phone Number_________________________
Address_________________________________________________________________________________
City______________________________________________State________Zip________________________
Birth Date______________Sex________Weight____________Height______SS#______________________
Names of Parents/Guardians_________________________________________________________________
Purpose for contacting us?___________________________________________________________________
Other doctors seen for this condition___________________________________________________________
Treatment________________________________________________________________________________
Check any of the following that pertains to your child:
Ear Infections
Digestive Problems
ADHD
Temper Tantrums
Asthma
Bed Wetting
Auto Accident
Headaches
Allergies
Seizures
A Fall
Chronic Colds
Colic
Recurring Fevers
Traumatic Birth
Adverse vaccination
Scoliosis
Constipation
Diarrhea
reaction
Other_________________________________________________________________________________
Family History____________________________________________________________________________
________________________________________________________________________________________
Name of Pediatrician___________________________________Date of last visit_______________________
Reason_______________________________Treatment___________________________________________
Number of doses of antibiotics your child has taken:
1) In last 6 months:___________________________________________
2) Total during his/her life:_____________________________________
Number of doses of other prescription medications your child has taken:
1) During last 6 months:________________________________________
2) Total during his/her life:______________________________________
Vaccination history:________________________________________________________________________
Feeding History:
Breast-fed
If yes, how long?_________________
Formula If yes, how long?_________________
Introduced solids at ________ months. Cow’s milk at ________ months.
Prenatal History:
Complications during pregnancy?
Explain_________________________________________________
Ultrasounds during pregnancy?
How many?_____________________________________________
Medications during pregnancy/delivery?
List them_________________________________________
Cigarette/alcohol use during pregnancy?
Frequency_________________________________________
Location of Birth
Hospital
Home
Other__________________________________________
Birth intervention
Forceps
Vacuum Extraction
C-section
Delivery complications?
No
Yes___________________________________________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2