Greater Cleveland Pediatrics - Medical History Form

Patient Medical History

Please complete this HIPAA secure form to the best of your ability. Thank you!
Family Demographics:
Date Completed:*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Parent/Guardian 1 and relationship to patient*
Parent/Guardian 1 Cell phone*
Please enter a valid phone number.
Parent/Guardian 1 Birthday*

MonthDayYear
Date
Parent/Guardian 1 Email*
example@example.com
Parent/Guardian 1 Occupation and Workplace*
Name of Parent/Guardian 2 and relationship to patient
Parent/Guardian 2 Cell phone
Please enter a valid phone number.
Parent/Guardian 2 Birthday

MonthDayYear
Date
Parent/Guardian 2 Email
example@example.com
Parent/Guardian 2 Occupation and Workplace
Patient Cell Phone Number (if available)
Please enter a valid phone number.
Patient Email (if available)
example@example.com
Home Phone Number
Please enter a valid phone number.
Please indicate primary contact phone number:*

Parent/Guardian 1 Cell phoneParent/Guardian 2 Cell phonePatient Cell phone

Social History:
Please indicate who lives at home with the child (please include all households):
Please describe any special living arrangements or other social history regarding your family that would be important for your doctors to be aware:
(Adoption, recent change in family dynamics due to divorce, separation, death, etc)
What is the age of your home and has it ever been tested for Lead?
Is your child exposed to tobacco in the car, at home, or with a caretaker:

YesNo
Are there guns in your home or childcare location?

YesYes and stored in a locked cabinet, unloaded, and with ammunition stored separately?No

Child's Medical History:
List any medical problems for which your child has been repeatedly treated:
(e.g., recurrent ear infections, recurrent strep, chronic abdominal pain/diarrhea/constipation)
Does your child see a sub-specialist for any of the above problems? If yes, which specialty, which doctor, and which hospital affiliation?
(Hospital affiliation: UH, CCF, Metro, Akron Children's, Nationwide Children's, etc)
List any hospitalizations including for what medical problem, age of child and month/year of hospitalization:
(e.g., RSV: Age 6 months, February 2020)
List any surgeries including which surgeon, which hospital affiliation, age of child and year performed:
(e.g., Ear tube placed at UH, Dr. Otteson - age 18 months, April 2019)
List any broken bones or severe injuries, including location of injury and year:
(e.g., June 2019: fractured left wrist)
Has your child had any problems with sleep?
Do you have any concerns regarding your child's mental health? If yes, please describe:
Do you have any concerns regarding substance use/abuse or other risky behaviors? If yes, please explain:
Please describe any new or other concerns you have regarding your child's health:

List current medications (Including name, dose, frequency taken and for which medical problem medication was prescribed). This should include any prescribed or OTC medications, vitamins, and supplements.
(e.g., Peanut Allergy: Epipen 0.3mg as needed for allergic reaction)
List any MEDICATION Allergies (Include reaction, age and year diagnosed):
(e.g., Amoxicillin allergy: hives and lip swelling. June 2018, age 9 months)
List any FOOD Allergies (Including reaction and year diagnosed):
(e.g., Sesame allergy: hives and wheezing, August 2019, age 18 months)
Has your child seen an Allergist for the above allergies? If yes, which doctor and when?
Is your child required to carry an Epipen due to any of the above allergies?

YesNoUnsure
NUTRITION/FEEDING: Please describe any past or present issues regarding your child's eating habits, nutrition, etc:
Who is your child's dentist and when was his/her last visit?

Developmental History:
Has your child met typical developmental milestones (language, social skills, motor skills, etc): Yes or No? If NO, please describe:
What age did your child start smiling and laughing?
What age did your child sit up independently?
What age did your child start using a pincer grasp to feed him/herself?
What age did your child start walking?
What age did your child first start talking and then start speaking in multi-word phrases?
Do you have any concerns about your child's speech?
Do you have any concerns about your child's gross or fine motor skills?
(e.g., Tommy does not seem to be as strong as his sister, or, Tommy is not able to feed himself yet)
Do you have any behavioral concerns regarding your child?
Have you ever been concerned that your child might have autism? If yes, please explain:
Has your children ever received speech, physical, occupational, or feeding therapy? If yes, at what age(s) and where?
(e.g., Speech therapy - age 22 months to 3 years. CCF Beachwood.)

School and Learning History:
Where does your child attend school? Which grade is he/she in currently?
Please describe your child's typical school performance:
Does your child receive any support services while at school? Please indicate whether or not you feel your child's school is meeting the needs of your child.
(e.g., IEP, 504 plan, participating in the gifted program)
List any extracurricular activities or sports:

Vaccination History:

Please provide a copy of your child's vaccine record.

Email copy of vaccine record to: admin@clepeds.com
Is your child fully up to date for his/her age with all recommended childhood vaccinations?

YesNoUnsure
Have you declined vaccinations for any reason? If yes, please explain why:
Thank you for taking the time to complete this medical record form. We understand it is a lot! This infomation will be very helpful in allowing us to take the best possible care of your child.

We are looking forward to seeing you in the office!

Thank you,

Greater Cleveland Pediatrics
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