Health Information Background Form (Child: 2 Years Or Younger) printable pdf download

Name: _______________________________________

Date:____________________________________

HEALTH INFORMATION BACKGROUND (Child: 2 Years or Younger)

Please take a few minutes to complete the following, describing your child’s usual condition. His/her current

problem will be discussed in depth with your doctor.

Did child’s mother have any complications or illnesses during pregnancy? ______If yes, explain____________

__________________________________________________________________________________________

Medications taken during pregnancy_____________________________________________________________

Was child born at term (40 weeks)? ________ If not, how early/late? ________________________

(Circle One) Delivery Vaginal or Caesarean Section?

Please explain any difficulties during labor and or

delivery:___________________________________________________________________________________

__________________________________________________________________________________________

Child’s birth weight ______ length ________ single delivery? ____ Did child leave hospital with mother?_____

Does the child have? (check if yes):

Has your child ever had? (if yes give the date)

___Feeding Problems

___Birth Defects

________Ear Infections ________Pneumonia

___Breathing Problems

___Jaundice

________Chicken Pox ________Mumps

___Metabolic Problems

___Liver Problems

________Tuberculosis ________Measles

___Cystic Fibrosis

___Thyroid Disease

________Seizures

________Croup

___Bowel or Bladder Problems

________Anemia

________Other explain

_________________________________________________________________________________________

__________________________________________________________________________________________

Does child breastfeed? ________ How often and for how long? ______________________________________

Type of formula? __________________ How often and how much? ___________________________________

Does child take vitamins? ________

Age (approximate) when child:

Lifted head while laying on stomach ______________

Was able to roll over_______________

Could sit up without help _______________

Spoke first word__________________

Spoke in a sentence _______________

Started solid foods_________________

Is child up to date for age with immunizations? ______ If no, which were missed? ________________________

__________________________________________________________________________________________

Any reactions to previous immunizations? _______________________________________________________

Any Hospitalizations?________________________________________________________________________

Surgeries? ________________________________________________________________________________

Allergies? _________________________________________________________________________________

Medications? _______________________________________________________________________________

Do any illnesses or conditions run in the child’s family? __________ If yes, explain ______________________

__________________________________________________________________________________________

Other Concerns or problems we should know about:________________________________________________

__________________________________________________________________________________________

Health Information Background Form (Child: 2 Years Or Younger)

Related Articles

Related forms

Related Categories