Pediatric Medical Questionnaire - Over Age 5
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1
2Patient Name:______________________________________
Today’s Date _______________
Cypress Physicians Association
Pediatric Medical Questionnaire – OVER AGE 5
Date of Birth:_________Previous medical care – Dr. _____________________ Last Well Exam: ________
Last Vision Exam:
Last Dental Exam:
Reason for today’s visit
Date Began
1.
2.
3.
Past Medical History:
Immunizations up to date?
Yes
No
Unsure – Please have your shot record available
Hospitalizations (when-where-why)
Serious injuries or ER visits (when-what)
Please mark (X) if your child has had problems below.
Asthma/Wheezing
Thyroid problems
Diabetes
Joint problems
Pneumonia
Headaches
Jaundice
Urinary infections
Heart problems
Seizures
Reflux
Hearing problems
Heart murmur
Bleeding tendency
Eczema
Vision problems
Learning disability
Blood transfusion
Skin infections
Other:
ADHD/ADD
Anemia
Ear infections
Developmental
Allergies/hay fever
Cancer
delay
Past Surgical History: (please indicate year)
Appendix
Bone surgery
Ear tubes
Tonsils/Adenoid
Circumcision
Other:
Medications: list all prescription and over-the-counter medications or supplements
Name
Dosage
Frequency
Indications/Use
Allergies to Medication/Food/Other?
Developmental History
Did your child have any developmental problems?
Compared to other children his/her age, is your child
advanced
same
behind
Problems with
bedwetting
tantrums
hyperactivity
speech
learning difficulties
For Females: Age at first menstrual period _______ Last menstrual period _______________________
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