Pediatric Patient Medical History Form
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1
2PEDIATRIC PATIENT MEDICAL HISTORY FORM
Date
Child’s Name
Nickname
DOB
M
F
Previous Physician
Request for Records Transfer
Date of Last Well Child Exam
Complete
Y
N
Mother’s Full Name
Father’s Full Name
Step-Mother’s Full Name (If Applicable)
Step-Father’s Full Name (If Applicable)
Custodial Provider’s Full Name (If different from above)
Relationship to Patient
Birth History
Birth Weight ________ Preg#______ Mom’s age______
Was the birth
□ Vaginal ?
□ Cesarean? □ Early? □ Late?
If birth was early, how many weeks early? ______________
If Cesarean, why? ___________________________________
Did mother have any illnesses/problems with her pregnancy? □ Yes □ No Explain ____________________________________
Did baby have any problems right after birth? □ Yes □ No Explain_________________________________________________
Before mother knew she was pregnant or at any time during her pregnancy did she:
□ Smoke Cigarettes (amount)_________________________
□ Drink Alcohol (amount) ________________________
□ Use “street” drugs (type)___________________________
□ Use Prescription Drugs (type)____________________
Was initial feeding □ Breast Milk? □ Formula?
Current and Past History
Is your child currently on any medication?
□ Y
□ N
Explain_________________________________
Does your child have any serious or chronic illnesses?
□ Y
□ N
Explain_________________________________
Has your child had serious injuries or accidents?
□ Y
□ N
Explain_________________________________
Has your child had any surgeries?
□ Y
□ N
Explain_________________________________
Has your child ever been hospitalized?
□ Y
□ N
Explain_________________________________
Is your child allergic to any medications?
□ Y
□ N
Explain_________________________________
Has your child ever reacted to immunizations?
□ Y
□ N
Explain_________________________________
Does Your Child Have Or Has Your Child Ever Had:
Asthma, recurrent cough, bronchitis, or pneumonia
□ Y
□ N
Explain_________________________________
Nasal allergies or eczema
□ Y
□ N
Explain_________________________________
Frequent ear infections or sore throat
□ Y
□ N
Explain_________________________________
Problems with ears or hearing
□ Y
□ N
Explain_________________________________
Problems with eyes, vision or teeth
□ Y
□ N
Explain_________________________________
Frequent headaches or other neurologic problems
□ Y
□ N
Explain_________________________________
Frequent abdominal pain
□ Y
□ N
Explain_________________________________
Constipation requiring doctor visits
□ Y
□ N
Explain_________________________________
Bladder/kidney problems or bedwetting
□ Y
□ N
Explain_________________________________
Any heart problems/murmur
□ Y
□ N
Explain_________________________________
Anemia or bleeding problem
□ Y
□ N
Explain_________________________________
Thyroid or other gland problem
□ Y
□ N
Explain_________________________________
Diabetes
□ Y
□ N
Explain_________________________________
ADD/ADHD
□ Y
□ N
Explain_________________________________
Mental Health Issues
□ Y
□ N
Explain_________________________________
Use of drugs or alcohol
□ Y
□ N
Explain_________________________________
Tobacco use
□ Y
□ N
Explain_________________________________
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