Pediatric Health History Form Page 3
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1
2
3SCHOOL HISTORY:
Did/does your child attend school or preschool?
No
Yes
Current grade __________ Name of school _____________________________________________
Any concerns about school performance? _______________________________________________
Any concerns about relationship with: Teachers
No
Yes
Students
No
Yes If more than 4 years old: does your child have a best friend?
No
Yes
Sports/exercise: Type _______________ How often? __________ How long (minutes)? ______
REVIEW OF SYMPTOMS: Please check (√) any current problems your child has on the list below:
Constitutional
Respiratory
Allergy
Fevers/ chills/excessive sweating
Cough/ Wheeze
Hay Fever/ itchy eyes
Unexplained weigh loss/gain
Chest Pain
Neurological
Headaches
Eyes
Gastrointestinal
Squinting/ crossed eyes
Nausea/vomiting/ diarrhea
Weakness
Ears/Nose/Throat
Constipation
Clumsiness
Unusually loud voice/hard of hearing
Blood in bowel movement
Psychiatric/ Emotional
Mouth breathing/ snoring
Speech problems
Genitourinary
Bad Breath
Bedwetting
Anxiety/stress
Frequent runny nose
Pain with urination
Problems with sleep/nightmares
Problems with teeth/gums
Discharge: penis or vagina
Depression
Nail biting/thumb sucking
Cardiovascular
Musculoskeletal
Tires easily with exercise
Muscle/joint pain
Bad temper/breath holding/jealousy
Shortness of breath
Skin
Blood/ Lymph
Fainting
Rashes
Unexplained lumps
Unusual moles
Easy bruising/ bleeding
Safety:
When your child is in the car does he use:
An infant seat
A booster seat
A seat belt only
Do you have smoke detectors at home
Yes or
No
Dos your child wear a helmet for Bike/ Scooter or ATV
Yes or
No
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