Medical History Form - Pediatric
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1MEDICAL HISTORY FORM
Pediatric
Name:_____________________________
Date _____________________
Date of Birth:_______________________
Allergies (to drugs, foods):__________________________________________________________________
Medications (including vitamins and fluoride):___________________________________________________
Diet (including milk): ____________________________________________________________________
Birth History (please circle): Normal vaginal delivery
C-section
Born term (close to due date)
Born premature
Complications after delivery: ________________________________________________________________
Past Medical History: Please circle the conditions your child has had or currently has.
Anemia
Eye problems
Kidney problems
Sinusitis
Seizures
Asthma
Ear infections
Urinary tract infection
Strep throat
Chicken pox
Arthritis
Hearing problems
Heart murmur
Pneumonia
Thyroid problems
Cancer
Jaundice
High blood pressure
Rashes
Positive TB test
Diabetes
Hepatitis
Rheumatic fever
Broken bones
Blood transfusion
Other ___________________________________________________________________________________
Surgeries and Hospitalizations:
Reason
Year
Hospital
Doctor
____________________________
________
______________________ ____________________
____________________________
________
______________________ ____________________
____________________________
________
______________________ ____________________
Developmental History:
At what age did your child first: Walk? _________ Talk? __________
Do you have any concerns about your child’s learning, development, or behavior? _______________________
Family Medical History:
Name
Age
Medical Problems
(e.g., asthma, history of
Occupation
heart attack or stroke, cancer, etc.)
Father: _____________________ _____ _______________________________________ ______________
Mother: ____________________ _____ _______________________________________ ______________
Brother: ____________________ _____ _______________________________________
Sister: ______________________ _____ _______________________________________
___________________________ _____ _______________________________________
Immunizations up-to-date? ______
Last full physical exam: ________ Last dental exam: __________
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