Pediatric Health History

Family Medicine Associates of Midland, p.c. - Pediatric Health History

Date

Patient's Full Name*

First NameLast Name

DOB*

MaleFemaleOther

Parent 1:*

Parent 2:

SingleMarriedWidowedSeparated

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone#*

Please enter a valid phone number.Format: (000) 000-0000.

Cell#*

Please enter a valid phone number.Format: (000) 000-0000.

Parent 1 Work

Please enter a valid phone number.Format: (000) 000-0000.

Parent 2 Work

Please enter a valid phone number.Format: (000) 000-0000.

Parent/Guardian Employer:

Parent 1:*

Parent 2:

Name of Insurance

Policy #

Group #

Subscriber

First NameLast Name

DOB

Employer

Upload insurance card

Today's Visit:

Reason/Problem/Contributing factors:*

How long has child had this problem?*

MildModerateSevere

Hospitalizations/Surgeries/ - include dates

Allergies

Current Medications:

Immunizations:

Health DeptDoctor's officeN/A

YesNo

Social History:

Pets:

School Attending/Current Grade*

Hobbies/Interests:

YesNo

NeverRarelyModerateDaily

NeverPreviously, but quitCurrent

packs per day*

NeverYes

Type & frequency*

Family Medical History:

.*

Rows	Age	Diseases/If deceased, cause of death if known
Parent 1
Parent 2
Siblings
Siblings
Parent 1's Father
Parent 1's Mother
Parent 2's Father
Parent 2's Mother

Other major illnesses in the family?

Please answer all the following questions

Has your child recently experienced:

Constitutional*

Rows	No	Yes	When?
Good General Health
Recent weight change
Fever
Fatigue
Headaches

Eyes*

Rows	No	Yes	When?
Eye disease or injury
Wear glasses or contact lenses
Blurred or double vision

Ears/nose/throat*

Rows	No	Yes	When?
Healing loss
Ringing in ears
Earaches or drainage
Sinus Infections
Frequent nose bleeds
Frequent mouth sores
Bad breath or bad taste
Sore throat or voice change

Cardiovascular*

Rows	No	Yes	When?
Chest pain
Sudden heart beat changes
Dizziness/passing out with exercise

Respiratory*

Rows	No	Yes	When?
Frequent coughing
Shortness of breath
Asthma or wheezing

Gastrointestinal*

Rows	No	Yes	When?
Loss of appetite
Nausea or vomiting
Frequent diarrhea
Painful bowel movements or constipation
Blood in stool
Stomach pain

Hematological/Lymphatic*

Rows	No	Yes	When?
Slow to heal after cuts
Easily bruise or blood
Anemia
Persistently enlarged glands

Genitourinary*

Rows	No	Yes	When?
Frequent urination
Burning/painful urination
Blood in urine
Incontinence/dribbling
Bed wetting/accidents

Musculoskeletal*

Rows	No	Yes	When?
Joint pain
Weakness of muscles or joints
Muscle pain or cramps
Back pain
Difficulty walking

Skin*

Rows	No	Yes	When?
Rash or itching
Change in hair or nails

Neurological*

Rows	No	Yes	When?
Frequent or recurring headaches
Convulsions or seizures
Numbness or tingling sensations
Light-headed or dizzy

Psychiatric*

Rows	No	Yes	When?
Memory loss
Confusion
Nervousness
Depression
Sleep problems

Endocrine*

Rows	No	Yes	When?
Glandular or hormonal problems
Thyroid disease
Excessive thirst or urination
Sleep problems

Exposure to:*

Rows	No	Yes	When?
Others with chronic cough
Nursing homes
Recent immigrants
International travel

Parent/legal guardian signature*