Pediatrics Medical History Form - Sutter Pacific Medical Foundation (Page 2 of 2) in pdf

FAMILY HISTORY:

Please indicate with a check (

) family members who have had any of the following conditions:

Mom’s

Dad’s

Mom’s

Dad’s

Medical Condition

Admin.

Mom

Dad

Sister

Brother

Mom

Dad

Mom

Dad

Sister

Brother

Sister

Brother

use only

Alcoholism

Anemia

Asthma

Autism

128

Autoimmune Disorder

Birth Defect/Congenital Anomaly

Bleeding Problem

Cancer, Breast

Cancer: Please Specify Type ________________

Depression

Diabetes

Eczema (Atopic Dermatitis)

Food Allergy

Gentic Disorder

Hay Fever (Allergic Rhinitis)

Hearing Disorder

Heart Attack/Coronary Artery Disease

High Cholesterol (Hyperlipidemia)

High Blood Pressure (Hypertension)

Immune Disorder

Inﬂammatory Bowel Disease (Crohns/UC)

Kidney Disease

Mental Retardation or Learning Disability

Migraine Headaches

Psychiatric/Mental Illness

Scoliosis

Stroke

Substance Abuse

Thyroid Disorders

Tobacco Use

30.5

Tuberculosis

Death before age 56 or reasons not listed above

Other:

SOCIAL HISTORY: Please list patient’s family and household members:

Name

Age

Relationship

Occupation/Employer

Cell Phone Number

_______________________________________________________________________________________________________________

Are your child’s parents

Married

Unmarried

Separated

Divorced (If divorced or separated, when?) _______

Child-care situation

Parents

Others (specify who and hours per day) __________________________________

_______________________________________________________________________________________________________________

Concerns about your child:

Alcohol use

Tobacco

Sexual activity

Aggressive behavior

Is violence at home a concern?

Yes

Are there pets in the home?

Yes

Are there guns in the home?

Yes

Do any family members smoke?

Yes

Pediatrics Medical History Form - Sutter Pacific Medical Foundation Page 2

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