Orange Pediatrics Page 3
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7ORANGE PEDIATRICS
251 Maitland Ave Ste 104 Altamonte Springs FL 32701
Ph: 407-557-2165
Fax: 407-369-4612
Health History (continued---
Patient’s Name____________________________________
ALLERGY TO MEDICATIONS:
ALLERGIES TO FOOD / ENVIRONMENT
None
None
Yes, please describe______________________
Yes, please specify_______________________
Allergy to Neomycin ?
Yes
No
Allergy to Latex ?
Yes
No
Allergy to EGGS?
Yes
No
IMMUNIZATIONS
Up to Date
Delayed
Did your child have any problems after taking immunizations?
No
yes________________
Opted for no immunization (please specify why) ____________________________
RELIGIOUS EXEMPTION
No
Yes
( includes strong moral or ethical conviction similar to a religious belief and requires a written statement
from parent/guardian)
MEDICAL EXEMPTION
No
Yes
( physical condition of child is such that the immunization would endanger life or health)
NUTRITION
Regular diet ___________________________
Special diet_________________
WIC ? Yes
No
Food history for infants (Birth to 12 months age):
Breast Milk
Name of formula ___________________
FAMILY HISTORY
No
Yes, specify__________________________
Any illnesses affecting children
No
Yes, specify__________________________
SIDS/Sudden Infant deaths in family
Heart attacks/disease at age less than 55 yrs ?
No
Yes, who_____________________________
Deaths in family at age <55 yrs due to heart disease
No
Yes, who_____________________________
High Cholesterol
No
Yes, who_____________________________
Obesity
No
Yes, who_____________________________
Asthma
No
Yes, who_____________________________
Diabetes
No
Yes, who_____________________________
Thyroid problems
No
Yes, who_____________________________
No
Yes, who_____________________________
Liver disease
No
Yes, who_____________________________
Cancer/leukemia
No
Yes, who_____________________________
Cystic fibrosis
No
Yes, who_____________________________
AIDS/ HIV + test
No
Yes, who_____________________________
Tuberculosis or anyone with positive TB skin test
Anemia
No
Yes, who_____________________________
No
Yes, who_____________________________
Hemophilia or other bleeding disorders
Migraines
No
Yes, who_____________________________
Allergies/hay fever
No
Yes, who_____________________________
Sinus problems
No
Yes, who_____________________________
Inherited disorders
No
Yes, who_____________________________
Lupus
No
Yes, who_____________________________
Mental/psychiatric illness
No
Yes, who_____________________________
Depression
No
Yes, who_____________________________
No
Yes
Does your child go to school ?
Grade at school _________
Name of school/daycare ______________
Do you have pets?
Yes ____________________________ None
Anybody smokes in the family (indoor or outside)?
None
Yes, Who?____________
Disclaimer: I acknowledge that my child’s information is up to date and correct to the best of my knowledge.
I shall update Orange Pediatrics about any changes to the above history at each future health visit.
Signature of Parent/ Guardian________________________ Today’s Date: ______________
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