Patient Medical History Questionnaire Form

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Patient Medical History Questionnaire
Today’s Date:_________
Patient’s Name:______________________________________Date of Birth:__________________Age Today:________________
Reason for Today’s Visit:_____________________________________________________________________________________
Do you have a record of this child’s immunizations with you today? No/Yes
PAGE 1
Please indicate answers by filling in the blanks or by circling ‘No’ or ‘Yes’
If adults in the household work outside the home, what
childcare arrangements are made for this
FAMILY HISTORY
child?________________________________________
Are the child’s parents both in good health? No/Yes
Circle any disease that the child’s siblings, parents,
st
_____________________________________________
grandparents, aunts, uncles or 1
cousins have: AIDS, alcohol
Are there any cultural concerns we need to be made aware
problems, allergies, asthma, blood disorders, cancer, diabetes,
of?___________________________________
drug problems, epilepsy, heart trouble, high blood pressure,
high cholesterol, inherited illness, kidney disease, liver
Who lives in the home with your child?
disease, lung disease, lupus, mental illness, multiple sclerosis,
muscular dystrophy, SIDS, tuberculosis, venereal disease,
Name
Relation
others.
Use this space to note which relative has which disease:
Sibling-Name/Birthdate / Sex/General Health Problem(s)
__________/________/____/______________________
__________/________/____/______________________
__________/________/____/______________________
__________/________/____/______________________
Have any siblings died? No/Yes
If yes, cause of death____________________________
PREGNANCY AND BIRTH
PAST MEDICAL HISTORY
Mother’s age at birth of child?___________________
Where has your child gone for check-ups until now?
Did mother have any illness during pregnancy?
_________________________________________
____________________________________
Date of last check-up:_______________________
Did she take any medications other than vitamins and iron?
Date of last dental check-up:__________________
No/Yes
Has your child had any allergic reactions to any medications,
What hospital/birth center?______________
foods, or insect bites?
No/Yes
Was the baby on time?
No/Yes
Which ones________________________________
Was the birth by C-section or vaginal?______
Has your child had a bad reaction to any immunizations?
Obstetrician/Midwife name______________
No/Yes
Which ones________________________
Pediatrician who saw the baby in the hospital?
Any hospitalizations/surgeries other than for birth?
No/Yes
____________________________________
For what?___________________________________
What was the birth weight _______Length________
____________________________________________
Did the baby have any trouble starting to breathe?
No/Yes
____________________________________________
Did the baby have any problems while in the hospital? No/Yes
Any chronic illnesses?
No/Yes
(Jaundice, infections, other?)__________________________
If so, please list_______________________________
Did the baby receive Hepatitis B vaccine in the nursery? No/Yes
Any serious injuries, broken bones, stitches?
No/Yes
Please note any other important facts:
What kind?___________________________________
______________________________________________
Are any medications taken regularly?
No/Yes
______________________________________________
Which ones?__________________________________
Has your child has/had any of the following: (circle)
Rubella(German Measles), Pertussis (Whooping Cough),
Strep Throat, Chicken Pox, Diptheria, Scarlet Fever,
Tonsillitis, Heart Murmur, Diabetes?

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