Pediatric Health History Form printable pdf download

PEDIATRIC HEALTH HISTORY FORM

Patient Name:_________________________________________

Prefers to Be Called:______________________ Date of Birth____________

Last, First, Middle Initial

First

Month/Day/Year

YES NO

Does the patient have any of the following conditions?

Low blood counts that require child to wear a mask

Persistent cough greater than 3 weeks OR a cough that produces blood

Been exposed to or have Tuberculosis

***If you answered yes to the question above please stop. Please speak to the reception desk for further instructions***

STATUS OF MEDICAL CARE INFORMATION:

Who is the patient’s primary medical doctor? _________________________________________________________________________________

Primary Medical Doctor:

Address _________________________________________________Phone: ___________________________

YES NO

Has the patient received care in the last year for a medical, emotional, developmental, or behavioral condition?

Are any of the patient’s doctors affiliated with University of Minnesota Health, University of Minnesota Children’s Hospital,

YES NO

University of Minnesota Physicians, or Fairview Health Services and Clinics?

YES NO

Has the patient had surgery or operations, emergency department visits, or overnight stays in the hospital?

YES NO

Is the patient vaccinated against common childhood infections?

YES NO

Is the patient currently pregnant?

MEDICAL CONDITIONS:

YES NO

Does the patient have a past history or a current disease, problem, or condition involving any of the following?

If yes, check all that apply.

Kidneys or Urinary Tract

Behavior , Emotions , or Mental health

Eating, Swallowing, Diet, Nutrition, or Digestion

Liver, Stomach, or Intestines

Birth Defects or Syndrome

Exercise or Body Movement

Lungs, Airway, or Breathing

Head, Eyes, Ears, Nose, or Throat

Blood or Bleeding

Muscles, Nerves, or Reflexes

Bones, Joints, or Connective Tissues

Hormones or Pregnancy

Senses or Sensory problems

Heart or Blood Vessels

Brain or Spinal Cord

Speech or Language

Complications Before or During Birth

Height or Weight

Skin or Glands

Infections or Immune System

Intellectual or Developmental Disabilities

Please describe the checked condition(s) above or provide information about any disease, problem, or condition not listed above

Pediatric Health History Form

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