Child And Pediatric Health History Form printable pdf download

Child and Pediatric Health History Form

Name: _____________________ Date of Birth: _____________________

Age: _______

Sex: M ___ F ___

Address: ______________________ City: ________________ Province: ________________ Postal Code: ____________

Parent's Home Phone: _______________________ Parent's Work Phone: ______________________________________

Parent's and Sibling's Names: __________________________________________________________________________

Parent's Email Address: ________________________________________________________________________________

Who may we thank for referring you? ____________________________________________________________________

Why This Form Is Important:

In this office, our focus is on helping people to function optimally so that they are stronger, healthier and

better able to adapt to the stresses of everyday life. This form gives us better understanding of the

physical, chemical and emotional stresses that can gradually accumulate over time to produce health

problems. Please complete this form as thoroughly as possible and the doctor will review it with you.

Current Health Concern

Health Concern: _____________________________________________________________________________________

When did it begin? ____________________________________________________________________________________

What relieves it?_____________________________ How often does it occur? ___________________________________

What aggravates it? __________________________________________________________________________________

Other Professionals Seen For Concern: ___________________________________________________________________

Treatment and Results: _________________________________________________________________________________

Birth History

Child’s gestational age at birth ________ weeks

Birth Weight ________

Length _________

Birth experience: ______ Midwife ______ Medical

Labour: ______ Spontaneous ______ Induced

Any procedures during birth?

_____ Forceps _____ Vacuum Extraction _____ C-section ____ Episiotomy

Any complications before or after birth? ( ) Yes

( ) No

If yes, please explain: ________________________________________________________________________________

Evidence of obvious birth trauma? ______ Bruising ______ Odd shaped head ______ Stuck in birth canal ______ Cord

around neck

Child And Pediatric Health History Form