New Patient Medical History Form

ADVERTISEMENT

Peninsula Pediatric Medical Group, Inc. 
50 South San Mateo Drive, Suite #180 
San Mateo, CA 94401 
650­342­4145      650­342­2070 fax 
Child’s Name: _________________________________ 
Today’s Date:________________________________ 
Person completing form_________________________ 
Relation to child:_____________________________ 
Purpose of FIRST VISIT:  Well Visit 
School/Sports Exam 
Particular Problem:  ________________ 
NEW PATIENT HISTORY ­ 
Your child's medical history is important.  Please provide the following 
information before your first visit; all information is kept confidentially along your child’s medical records. 
BIRTH HISTORY: 
Where was your child born?____________________________ Birth Weight__________________________ 
Was child’s mother ill or take any medications during pregnancy? ....................................... 
No    YES 
Was the delivery NOT on time (was baby born too early or late?) ........................................ 
No    YES 
Did your child have any trouble starting to breathe? ............................................................. 
No    YES 
Did your baby have problems in the hospital nursery (breathing, jaundice, infection, etc)? ... 
No    YES 
Did your infant remain in the hospital after mother was discharged? .................................... 
No    YES 
ALLERGIES / MEDICATIONS: 
Is your child ALLERGIC to any medicines or foods?..............................................  No          YES – List Below 
________________________________________________________________________________________ 
Are there any MEDICATIONS which your child takes regularly?...........................  No          YES – List Below 
________________________________________________________________________________________ 
Circle if your child takes:  vitamins        iron containing vitamins 
fluoride 
other nutritional supplements 
: 
ILLNESSES – Please list with dates
Hospitalizations 
Operations 
Serious Illness 
Serious Injuries / Fractures 
Does your child have any problem with HEARING or VISION?.......................................... 
No    YES 
Any history of CONCUSSSION or loss of consciousness?................................................... 
No    YES 
In the last 12 months, how many EAR INFECTIONS has your child had? _________  TONSILLITIS?_________ 
Please CIRCLE any illnesses below which your child has experienced: 
Atopic Dermatitis / Eczema 
Strep Throat / Scarlet Fever 
Sinus Problems 
Hives / Urticaria 
Chicken Pox (Varicella) 
Other special illnesses: 
Wheezing / Asthma 
Urine/Kidney/bladder infection 
Pneumonia / Bronchitis 
Seizure / Convulsion 
DIET / ELIMINATION: 
Do you have concerns about your child’s APPETITE or DIET? ........................................... 
No    YES 
Do you RESTRICT or AVOID items from your child’s diet for any reason? ........................ 
No    YES 
Has your child had recurring or severe DIARRHEA?........................................................... 
No    YES 
Has your child had problems with HARD or PAINFUL stools?............................................ 
No    YES

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

New Patient Medical History Form New Patient Medical History Form Medical
New Patient Medical History Form New Patient Medical History Form Medical
New Patient & Medical History Form New Patient & Medical History Form Medical
New Patient Past Medical History Form New Patient Past Medical History Form Medical
New Patient Vision & Medical History Form New Patient Vision & Medical History Form Medical
New Patient Health History Form New Patient Health History Form Medical
New Patient Health History Form New Patient Health History Form Medical
New Patient Medical History New Patient Medical History Medical
New Patient Medical History Questionnaire New Patient Medical History Questionnaire Medical
Patient Medical History Form Patient Medical History Form Medical

Related Categories

Parent category: Medical
Download
Go
Page of 2