Pediatric Health History Form - 6-10 Years Of Age

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Pediatric Health History Form
6 – 10 years of age
 M  F
DOB
Name
Today’s Date
PRENATAL & BIRTH HISTORY:
Did child’s mother receive prenatal care?  No  Yes
If yes: What month of pregnancy did prenatal care start? __________
Did child’s mother use alcohol, tobacco or any illegal drugs during pregnancy?  No  Yes
If yes: Please list type, amount and frequency _____________________________________________
Where was child born? ______________________________
Please indicate any medical problems during pregnancy  None  Specify: _______________________
List any complications at birth (if premature, how early?) _______________________________________
ALLERGIES/REACTIONS to food, medicines or vaccinations:
____________________________________________________________________________________
CURRENT MEDICATIONS (name, strength, frequency):
____________________________________________________________________________________
____________________________________________________________________________________
CHILD’S MEDICAL HISTORY:
 No  Yes, (list, with dates) ___________________________________________
Major Medical Problems:
___________________________________________________________________________________________
 No  Yes, (list, with dates)________________________________________
Hospitalizations/Operations:
___________________________________________________________________________________
 No  Yes, (list, with dates) ______________________________________
Broken bones/Severe Injuries:
___________________________________________________________________________________________
NUTRITION HISTORY:
Has child had any unusual feeding/dietary problems?  No  Yes If yes, specify ______________________
How many servings of fruit does child eat a day? _____ Vegetables? _____ Meat? _____ Dairy? _____
Does child drink soda/pop?  No  Yes If yes, how much per day? _________
Does child drink juice?  No  Yes If yes, how much per day? _________
Is child a good eater?  No  Yes
Does child eat junk food frequently?  No  Yes
DEVELOPMENT/BEHAVIORAL HISTORY:
Does child have any problems sleeping?  No  Yes If yes, explain_________________________________
Hours of sleep per night? _____ Does child have any problems with bedwetting?  No  Yes
Current grade in school_______ Any concerns about school performance? ________________________________
Any concerns about relationship with:
Teachers  No  Yes Peers  No  Yes If yes, explain _____________________________________________
Does child have any behavioral problems?  No  Yes If yes, explain _______________________________

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