Pediatric Health History Form - 6-10 Years Of Age (Page 2 of 2) in pdf

IMMUNIZATIONS:

Hepatitis B _____, _____, _____ DtaP _____, _____, _____, _____, _____ Influenza ________

Hib _____, _____, _____, _____Polio _____, _____, _____, _____ Rotavirus _____, _____, _____

Pneumococcal _____, _____, _____, _____ MMR _____, ______Varicella _____, _____

Hepatitis A _____, _____

DENTAL HISTORY

Has child been seen by a dentist?  No  Yes If yes, how often? ___________ Date of last visit? ________

VISION HISTORY:

Has child had a vision screening done? No  Yes If yes, when? ______ Does child wear glasses? No  Yes

FAMILY HISTORY

: Please indicate family members (parent, sibling, grandparent, aunt or uncle) with any of the

following conditions, if deceased due to a condition please put age at death:

Heart Disease ________________________ High Blood Pressure _________________________

High Cholesterol ______________________ Stroke ____________________________________

Cancer, specify type ___________________ Genetic Disorders ___________________________

Diabetes ____________________________

Asthma/COPD _____________________________

Anemia _____________________________

Alcoholism/Drug overdose ____________________

Other: __________________________________________________________________________

SOCIAL HISTORY:

Who lives at home?

Name

Age

Relationship

Name

Age

Relationship

____________________________________________________________________________________________

__________________________________________________________________________________________

Are the child’s parents  Married  Unmarried  Divorced  Separated

Child care situation  Parents  Other (specify who and how often) _____________________________________

Is violence/abuse at home a concern?  No  Yes

Safety:

Does child use a helmet and protective gear for bike riding, skateboarding, skating, etc?  No  Yes

Does child use booster seat/seat belts consistently?  No  Yes

Do you have firearms at home?  No  Yes

Does your house have a working smoke detector? No  Yes

Are household chemicals/cleaning products in locked cabinets?  No  Yes

Exposure/Habits:

Any concerns about lead exposure?  No  Yes

Do any household members smoke?  No  Yes

TV – hours per day watched by child ________________________

Computer – hours per day used by child __________________

Video games – hours per day played by child ________________

Parent Signature _______________________________ Reviewed by_________________________

Date _________________________________________

Pediatric Health History Form - 6-10 Years Of Age Page 2

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