Pediatric Health History Form
CHILD'S NAME:
DATE OF BIRTH:
/
Month
/
Day
Year
Date
AGE:
Would you like your child to be enrolled in the Texas Immunization Registry?
*
YES
NO
CHILD'S PREVIOUS DOCTOR / PRIMARY CARE PROVIDER:
PRESENT HEALTH CONCERNS:
MEDICINES/VITAMINS:
ALLERGIES TO MEDICINES OR VACCINATIONS:
PREGNANCY & BIRTH
Is this child yours by:
birth
adoption
stepchild
Other
Please indicate any medical problems during pregnancy
None
Other
Number of weeks Gestation
Select One
Preterm # of Wks
Full term (38-40wks)
Post term # of wks.
Delivery by
vaginal birth
caesarian
If caesarian why?
Birth weight:
Birth length:
Any medical problems during the baby’s newborn period
Yes
NO
If yes indicate problems:
NUTRITION & FEEDING
Was your child breastfed?
❑
No
❑
Yes If so, how
Was your child breastfed?
Yes
NO
If so how long?
Has your child had any unusual feeding/dietary problems?
No
Yes
If yes specify:
Milk intake now Type
cow milk
non-fat
1%fat
2%fat
whole milk
soy milk
rice milk
Average ounces per day (Note: 8 ounces are in 1 cup)
Girls only: Age at first menstrual period
DENTAL HISTORY has child been seen by a dentist?
No
Yes
Yes If so, date of last visit
/
Month
/
Day
Year
Date
EXPOSURES/HABITS Any concerns about lead exposure? (old home/plumbing/peeling paint)
No
Yes
Do any household members smoke?
No
Yes
SCHOOL/ DAYCARE
Not in school
In school Where?
Where?
Grade?
IDaycare?
Remedial/Special Ed?
Sports / exercise:
PAST MEDICAL HISTORY: Please describe any major medical problems and their dates:
Broken bones or severe sprains
Hospitalizations/Operations (with dates):
FAMILY HISTORY: Please circle any family history of the following (indicate who has/had the condition)
Alcoholism/drug abuse
Psychiatric disorders
High blood pressure
Asthma/hayfever/eczema
Heart disease or stroke before age 60
Bleeding/clotting problems
Inherited/genetic diseases
Seizures
Kidney disease
Birth defects
Thyroid disease
Social History Birthplace
Who lives at home?
Name
Age
Relationship
1
2
3
4
5
6
Are the child’s parents
married
unmarried
separated
domestic partner
divorced
Parents' occupations:
REVIEW OF ORGAN SYSTEMS:
Constitutional/Endocrine
Fevers/chills/excessive sweating
Unexplained weight loss / gain
Gastrointestinal
Nausea/vomiting/diarrhea
Constipation
Blood in bowel movement
Allergy
Sneezing/itchy eyes/runny nose
Eyes
Squinting/”crossed” eyes/asymmetric gaze
Type option 2
Cardiovascular
Tires easily with exertion
Shortness of breath
Fainting
Skin
Rashes
Unusual moles
Type option 3
Ears/Nose/Throat
Unusually loud voice/hard of hearing
Genitourinary
Bedwetting
Pain with urination
Discharge: penis or vagina
Psychiatric/Emotional
Speech Problems
Anxiety/stress
Problems with sleep/nightmares
Depression
Nail biting/thumb sucking
Bad temper/breathing holding/jealousy
Respiratory
Cough/wheeze
Weakness Blood / Lymph
Neurological
Headaches
Weakness
Clumsiness
Blood/Lymph
Easy bruising/bleeding
Unexplained lumps
Muscular / Skeletal
Muscle/joint pain
Submit
Should be Empty: