Patient Information Form Page 3
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7PEDIATRIC INITIAL HEALTH ASSESSMENT
Name of Child _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date of Birth ___ ./ _ _ / _ _
Birth History: (for patients less than
1
year old)
State, country child born _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
Pregnancy/Delivery problems
Delivery type
Post Partum complications _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Was baby discharged with mother? [ ]
Yes
[
] No Why? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Birthweight:
Ibs
.
oz.
Length of baby's hospital stay _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
Apgar
Medical History:
Allergies to food, environment, medications _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Hospitalizations _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Surgeries _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
Injuries/Accidents _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Significant illnesses
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Child has had:
o
Chickenpox
o
Seizures
o
Ear Infections
o
Hearing Problems
o
Sickle Cell DiseasefTrait
Present
Medications:
Prescription:
o
Weight Problems
o
Sinus Problems
OTB
o
Bladder
Infections
o
Heart Murmur
Family Medical History (Blood relative has had):
o
Anemia
0
Heart Disease
o
Sickle Cell DiseasefTrait
0
Diabetes
o
Asthma
0 Kidney Disease
o
Seizures
0 Mental Retardation
o
Anemia
o
Mumps
o
Measles
o
Headaches
o
Pneumonia
o
Hay Fever
o
Eczema
o
Vision Problems
o
Any other problems? _ _ _ _ _ _ _ _ _ _ _
_
o
Thyroid Problems
o
Tuberculosis
o
Stroke
o
Birth Defects
o
Deafness
o
Eczema
o
High Blood Pressure
o
Drug Abuse
o
Alcoholism
DOther _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
Social/Cultural History:
School Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ GmdeinSchool _ _ _ _ _ _ _ _ _ _ _
Language spoken at home
Number of
family
members living in same house:
Prima~caretakerofthechild
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
~
Name
Occupation
Mother _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
Father _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Sibling _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Sibling _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Sibling _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_
Sibling _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Environmental History:
DYes
0
No Exposure to tobacco smoke
DYes 0
No Alcohol use (age appropriate)
D
Yes
0
No,
Drug use (age appropriate)
DYes 0
No Tobacco use (age appropriate)
Provider comments _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
__
_ _ _ _ _ _ _
-,-_ _ _ _ _ _ _ _ _
_
Signature of provider who obtained/reviewed history
Date
a--- - - -
-
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Parent category: Medical