Pediatric Patient Medical History Form Page 2
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1
2Household Information
Please List All Those Living in the Child’s Home
Name
Relationship to Child
DOB
Are there siblings not listed above? If so, please list their full names and ages and where they live. ____________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Child Care:_______________________________________________________________________________________________________________________________
Smokers in household? □ Y □ N
Family Medical History (Parents, Siblings, Grandparents, Aunts and Uncles)
Have Any Family Members Had the Following:
Alcohol/Drug Abuse
□ Y
□ N
Who___________________________ Comments________________________________________
Allergies
□ Y
□ N
Who___________________________ Comments________________________________________
Asthma
□ Y
□ N
Who___________________________ Comments________________________________________
Birth Defects
□ Y
□ N
Who___________________________ Comments________________________________________
Blood Disorders
□ Y
□ N
Who___________________________ Comments________________________________________
Bone Disorders
□ Y
□ N
Who___________________________ Comments________________________________________
Cancer
□ Y
□ N
Who___________________________ Comments________________________________________
Diabetes
□ Y
□ N
Who___________________________ Comments________________________________________
Endocrine Disease
□ Y
□ N
Who___________________________ Comments________________________________________
Ear/Nose/Throat
Disorders
□ Y
□ N
Who___________________________ Comments________________________________________
Eye Disorders
□ Y
□ N
Who___________________________ Comments________________________________________
Gastrointestinal
Disorders
□ Y
□ N
Who___________________________ Comments________________________________________
Heart Disease
□ Y
□ N
Who___________________________ Comments________________________________________
High Blood Pressure
□ Y
□ N
Who___________________________ Comments________________________________________
High Cholesterol
□ Y
□ N
Who___________________________ Comments________________________________________
Immune Disorders
□ Y
□ N
Who___________________________ Comments________________________________________
Joint Problems
□ Y
□ N
Who___________________________ Comments________________________________________
Kidney Disease
□ Y
□ N
Who___________________________ Comments________________________________________
Liver Disease
□ Y
□ N
Who___________________________ Comments________________________________________
Lung Disease
□ Y
□ N
Who___________________________ Comments________________________________________
Migraine Headaches
□ Y
□ N
Who___________________________ Comments________________________________________
Metabolic Disorders
□ Y
□ N
Who___________________________ Comments________________________________________
Obesity
□ Y
□ N
Who___________________________ Comments________________________________________
Seizure Disorders
□ Y
□ N
Who___________________________ Comments________________________________________
Skin Disorders
□ Y
□ N
Who___________________________ Comments________________________________________
Stroke History
□ Y
□ N
Who___________________________ Comments________________________________________
Thyroid Disorders
□ Y
□ N
Who___________________________ Comments________________________________________
Mental Health History
□ Y
□ N
Who___________________________ Comments________________________________________
Other Medical History
□ Y
□ N
Who___________________________ Comments________________________________________
Other Medical History
□ Y
□ N
Who___________________________ Comments________________________________________
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