Pediatrics Medical History Form - Sutter Pacific Medical Foundation
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1
2Patient Pediatric
Health History Form
For well-child checks, please also use the appropriate well-child questionnaire
CHILD’S NAME: ______________________________________________ DATE OF BIRTH: _________________ AGE: ________
CHILD’S PREVIOUS DOCTOR/PCP: ____________________________________________________________________________
BIRTH AND PREGNANCY
What city was your child born in? ___________________________________ Name of hospital: ____________________________
Is this your child by:
Birth
Adoption
Step-child
Other: _______________________
Birth weight: ____________________________
Was your baby premature?
Y
/
N
Were there any significant medical problems during your pregnancy?
Y
/
N
Were there any significant complications during labor or the baby’s newborn period?
Y
/
N
If yes, to any of the above questions, please explain: _______________________________________________________________
_______________________________________________________________________________________________________________
GROWTH AND DEVELOPMENT
Have you or your prior pediatrician ever had any concerns about your child’s growth or development (speech/language,
social skills, motor skills, etc.)?
Y
/
N
If yes, please explain: ___________________________________________________________________________________________
Girls only:
Age at first period: __________________
PAST MEDICAL HISTORY
HAS YOUR CHILD:
Had any serious medical illness?
Y
/
N
Had broken bones/frequent or severe sprains?
Y
/
N
Had a history of asthma or wheezing?
Y
/
N
Had any mental or behavioral problems?
Y
/
N
Ever used an inhaler or nebulizer?
Y
/
N
Had a positive tuberculosis skin test?
Y
/
N
Had surgery?
Y
/
N
Been hospitalized overnight?
Y
/
N
If yes, to any of the above, please explain: ________________________________________________________________________
_______________________________________________________________________________________________________________
IMMUNIZATIONS Please bring your child’s immunization records to your appointment
Have you ever refused vaccines for your child?
Y
/
N
If yes, why? ___________________________________________________________________________________________________
MEDICATIONS AND ALLERGIES
Please list current medications, vitamins, and supplements, even those used intermittently: _____________________________
_______________________________________________________________________________________________________________
Please list allergies or reactions to medications, vaccines or foods
Allergy
Reaction
______________________________
__________________________________
______________________________
__________________________________
______________________________
__________________________________
______________________________
__________________________________
Form 143453 (July 2010)
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