Medical History Form

Medical History/Historia Medica
Child's Name/Nombre de Nino*

First Name/Primer NombreLast Name/Apellido
Birth Date/Fecha de Nacimiento*

MonthDayYear
Date/Fecha
Sex/Sexo*

Male/MuchachoFemale/Muchacha
Check the conditions that apply to you or to any members of your immediate relatives:*

Asthma/AsmaCancer/CancerHeart disease/Enfermedad de corazonDiabetes/DiabetesHypertension/Alta tension de la sanrgrePsychiatric disorder/Desorden psiquiatraEpilepsy/Epliepsia
Does your child have any medical problems/Su nino tiene algo de los siguientes?*

Chest pain/Dolor de pechoRespiratory problems/Problemas respiratoriaCardiac disease/Enfermedad de corazonBlood disease/Enfermedades de la sangreLymphatic/LimfaticoNeurological/Problemas neurologicasPsychiatric/PsiquiatraGastrointestinal/GastrointestinalGenitourinary/Problemas urinarias o de los ovarios, pene.Weight gain/Subita de pesoWeight loss/Perdida de pesoMusculoskeletal
Please elaborate or add anything not covered.
Is your child currently taking any medication/Su nino esta tomando medicamentos?*

Yes/SiNo/No
If so, list the medications here/Si es cierto, escribe las medicinas aqui.
Are there any medication allergies/Hay allergias a medicinas?*

Yes/SiNo/NoNot Sure/No es seguro
Is so, list them here/Si hay allergias, escribe las medicinas aqui.
Is there any history of using tobacco/Se usa tobacco?*
Is there any history of using illegal drugs/Se usa drogas?*
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Medical History/Historia Medica