Skylands Pediatrics Adolescent Health History Form
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1SKYLANDS PEDIATRICS
ADOLESCENT HEALTH HISTORY FORM
Please have patient/teen complete before your physical exam
Name of Child ________________________________________________ Birth date ______________________
Circle Yes or No to the following questions. Explain all ‘Yes’ responses in the space provided (to the right).
1. Injury or illness since last checkup?
Yes / No _______________________________
2. Chronic illnesses, hospitalizations or surgeries?
Yes / No _______________________________
3. Any medications, supplements, herbs of any type?
Yes / No _______________________________
4. Allergies to medications, insects or food?
Yes / No _______________________________
5. Dizziness, passed out, chest pain with exercise?
Yes / No _______________________________
6. History of high blood pressure or heart murmur?
Yes / No _______________________________
7. History of sudden death in a close relative <50 years old? Yes / No _______________________________
8. Ever restricted from sports by a physician?
Yes / No _______________________________
9. Any skin problems?
Yes / No _______________________________
10. History of concussion, “knocked out”, unconsciousness,
memory loss, seizure, or severe/frequent headache?
Yes / No _______________________________
11. Problems while exercising in the heat?
Yes / No _______________________________
12. Asthma, allergies, wheezing, difficult breathing?
Yes / No _______________________________
13. Glasses, contacts, vision or eye problems?
Yes / No _______________________________
14. Strain, sprain, fracture, joint pain or swelling?
Yes / No _______________________________
15. For girls: How long ago was your last period?
Yes / No _______________________________
Concerns regarding periods?
Yes / No _______________________________
16. Under the care of any other health care provider?
Yes / No _______________________________
FAMILY HISTORY: Please mark Yes or No – if Yes, list relationship of individual
Medical Condition
Yes
No
If Yes, list relationship of individual
Alcoholism
Bleeding Problems
Cancer, Breast/Ovarian
Cancer, Colon
Cancer, Melanoma
Cancer, Prostate
Heat Attack/Heart Disease
Depression
Diabetes
High Cholesterol
High Blood Pressure
Stroke
Substance Abuse
Thyroid Disorders
Other
CONCERNS: Please review this list and check if you have a concern.
Physical Development
Emotional Development
Sleep Patterns
Weight
Amount of Physical Activity
Diet/Nutrition
Relationships with parents and family
Choice of friends
Self image or self worth
Excessive moodiness or rebellion
Lying, stealing or vandalism
Depression
Violent / gang activity /guns / weapons
School grades / absences
Smoking or chewing tobacco
Drug use
Alcohol use
Sexual behavior
Sexual orientation (heterosexual, gay or bisexual)
Pregnancy risk
Sexually transmitted diseases (STDs)
Any other concerns?____________________________
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