Pediatric Health History Form
CHILD’S NAME: ______________________________ DATE OF BIRTH: ________________ AGE: _______
CHILD'S PREVIOUS DOCTOR/PRIMARY CARE PROVIDER: ______________________________________
PRESENT HEALTH CONCERNS:_____________________________________________________________
MEDICINES/VITAMINS: ___________________________________________________________________
HERBS/HOME REMEDIES:_________________________________________________________________
ALLERGIES/REACTIONS TO MEDICINES OR VACCINATIONS: __________________________________
PREGNANCY & BIRTH
Where was your child born? ___________________________________
Is the child yours by:
Birth
Adoption
Stepchild
Other: _________________________________
Please indicate any medical problems during pregnancy
None
Specify:
_______________________________________________________________________________________
Delivery by
Vaginal birth
Caesarean If Caesarean, why?_________________________________
Birth weight: ___________ Birth length: _______________ APGAR score 1 min.____ 5 min.____
Please indicate any medical problems during the baby’s newborn period:
None If premature, how early?________ Other problems: ____________________________________
NUTRITION & FEEDING
Was your child breastfed?
No
Yes If so, how long? _____________________________________
Has your child had any feeding/dietary problems?
No
Yes If yes, specify:
______________________________________________________________________________________
______________________________________________________________________________________
Milk intake now: Type:
Cow's milk ( Nonfat
1% fat
2% fat
Whole milk)
Soy milk
Rice milk
Average ounces per day (Note: 8 ounces = 1 cup)__________
SLEEP
Hours per night________________________ Naps (number & length)________________________
Any sleep problems?_____________________________________________________________________
DEVELOPMENT
At what age did your child:
Sit alone_______ Walk alone________ Say words______ Toilet train (daytime) _______
Girls only: Age at first menstrual period__________
DENTAL HISTORY: Has child been seen by a dentist?
No
Yes If so, how
often?____________ Date of last visit_______
Water Source: City or Well?_________________________