Pediatric Health History Form Page 2
Download a blank fillable Pediatric Health History Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Pediatric Health History Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3IMMUNIZATIONS/INFECTIOUS DISEASES: Please bring your child’s immunization records to your appointment.
Has your child had:
Chickenpox
Measles
Mumps
Rubella
Meningitis
Tuberculosis (TB)
EXPOSURES/HABITS: Any concerns about lead exposure? (old home/plumbing/peeling paint)
No
Yes
Do any household members smoke?
No
Yes
TV-hours per day_______ Computer-hours per day_______ Video games-hours per day________
PAST MEDICAL HISTORY: Please describe any major medical problems and their dates.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Hospitalizations/operations (with dates): ___________________________________________________
Broken bones or severe sprains: ____________________________________________________________
FAMILY HISTORY: Please indicate the current status of your immediate family members:
Please indicate family members (parent, sibling, grandparent, aunt or uncle) with any of the following
conditions:
Alcoholism
High Cholesterol
Cancer, specify type
High Blood Pressure
Heart Attack
Stroke
Depression/Suicide
Other
Diabetes
Other
SOCIAL HISTORY:
Who lives at home?
Name
Age
Relationship
Highest Education Level
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Are your child's parents
Married
Unmarried
Separated
Divorced If divorced or separated,
when? _____
Mother's Occupation __________________________ Mother's Employer ______________________
Father's Occupation __________________________ Father's Employer _______________________
Child care situation
Parents
Others (specify who and hours per day)________________________
Concerns about your child:
Alcohol use
Tobacco
Sexual activity
Aggressive behavior Is
violence at home a concern?
No
Yes Are there guns in the home?
No
Yes
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical