Pediatric Medical/family History Form (Page 2 of 2) in pdf

Pediatric Medical/family History Form Page 2

Please complete the back as well

Allergies (Please check allthat apply)

I Medications

n food

n Other

Family History (Please check any family medical history that you feel is relevant to your health care this may

include, but is not limited to the following)

[J Hypertension

f]Alcoholism

flAnemia

I Diabetes

r Heart Disease

flseizures

! Depression

fl cancer

[J Asthma

n Allergies

I Other

Relation

Name

Mother

Date of Birth

Father

Brother

Sister

Additional History

Patient's primary ca regiver

Special Needs

Seat Belt Use n Yes I No

lead Risk Assessment

Sunscreen Use? n Yes ! No

Lives in or regularly visits a house / child care facility built before 1970 or that has been recently

n yes I lto

remodeled?

Lives near a heavily traveled highway or battery recycling plant or lives with an adult whose job or

I yes f] No

hobby involves exposure to lead?

Has a sibling or playmate who has or did have lead poisoning?

TB Risk Assessment

Exposure to TB?

[1 Yes f] No

Radiographic

or clinical findings?

I yes I No

lmmigrant from areas with high

prevalence?

E Yes fl No

Other medical risk factors?

n yes I No

Please list any medical history you feel we need to help better serve you that has not been listed above.

nYes [] No

Pediatric Medical/family History Form Page 2

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