Primary Health Solutions-Pediatric History Form Birth To 12 Years Of Age April 2010 Page 2
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2PEDIATRIC HISTORY FORM CONTINUED
Child’s Medical History: Please circle Yes or No
Is the child allergic to medicine or anything else?
Yes
No
If yes, allergic to what?_________________________________________________________________________
Does the child take any medicines?
Yes
No
If yes, what medicine?_________________________________________________________________________
Has the child ever been in the hospital overnight?
Yes
No
If yes, when and why?_________________________________________________________________________
Has the child had any surgery?
Yes
No
If yes, when and what type of surgery?____________________________________________________________
Does the child have a hearing or speech problem?
Yes
No
If yes, what type of problem?____________________________________________________________________
Does the child have a vision problem?
Yes
No
If yes, what type of problem?____________________________________________________________________
Has the child had problems with or been treated for: Please check YES or NO
YES NO
YES NO
YES NO
Anemia
Hay fever
Seizures
Asthma
Heart
Skin
Bowel Problems
Kidney Problems
Stomach
Breathing
Lead Problems
Other
Chickenpox
Muscles
Does the child have any other problems that you would like to discuss?
________________________________________________________________________________________________
Family Experience: List other adults or children that live in the house with the child, other than the immediate family, and their
relationship to the child:
Other household member
Relationship to the child
Was the house or apartment the child lives in built before 1970?_____________________________________________
Are the child’s parents divorced or not living together?
Yes
No
If yes, what are the custody arrangements for the child?____________________________________________________
________________________________________________________________________________________________
Who has the main responsibility for taking care of the child?_________________________________________________
Does the child go to daycare or a babysitter?
Yes
No
Does the child go to preschool or Head Start?
Yes
No
If the child is in school, how does he/she do in
school?_____________________________________________________________________
Does anyone who lives in the house with the child smoke?
Yes
No
If yes, who smokes? _______________________________________________________________________
Has the child ever been abused physically or sexually?
Yes
No
Has the child ever seen someone physically or sexually abused?
Yes
No
Is there a gun in the home?
Yes
No
For office use: Reviewed by:
(Provider Signature) Date:
Page 2
4/2010
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