Pediatric Health History Form
Lamoille-500.34J
All Questions contained in this form are confidential and will become part of your medical record.
Name:
Date of Birth:
-
Month
-
Day
Year
Preferred name (nickname)
Date of last Well-child exam
-
Month
-
Day
Year
Gender Identification:
Male
Transgender
Female
Preferred pronouns
Allergies:
(Please list medications, food, and Seasonal allergies with associated reactions)
What:
Reaction:
What:
Reaction:
What:
Reaction:
Medications:
(Please list all medications including over the counter, supplements, and vitamins.)
Name:
Start:
-
Month
-
Day
Year
Strength:
How often:
Name:
Start:
-
Month
-
Day
Year
Strength:
How often:
Name:
Start:
-
Month
-
Day
Year
Strength:
How often:
Medical History:
Birth History:
Vaginal
Cesarean
If premature, Born at
Were there any complications during the pregnancy or birth?
Yes
No
Did the mother smoke or use alcohol, drugs, or medications during pregnancy?
Yes
No
Have there ever been any concerns about your child’s development or growth?
Yes
No
Has your child missed any routine immunizations?
Yes
No
Has your child stayed overnight at a hospital?
Yes
No
Has your child ever had surgery or anesthesia for a procedure?
Yes
No
Has your child had recurrent infections?
Yes
No
Does your child have any chronic medical conditions?
Yes
No
If Yes to any of the above, please explain:
Patient Name:
Date of Birth:
-
Month
-
Day
Year
Social Environment:
Home is:
Rented by caregiver
Owned by caregiver
Other
Water:
Well water
Town water w/ fluoride
Town water w/o fluoride
Bottled water
Parents:
Married
Divorced
Live together
Separated
Remarried
Incarcerated
Child is:
In custody of parents
Adopted
In foster care
Daycare/School:
Family Resources:
WIC
Reach Up
3 Squares
Children’s Integrative Services
Head Start
Nurse Family Partnership
Other
Social History:
Who lives in the same home as your child (either part time or full time)
Name
Age/DOB
Relationship to child
Occupation
Smokes?
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Family Medical History:
Age
Deceased
Smoker
Asthma
Cancer
Depression
Diabetes
Heart
Disease
High
Cholesterol
Thyroid
Disease
High Blood
Pressure
Stroke
Substance
abuse
Suicide
Mother
Father
Sibling 1
Sibling 2
Paternal
Grandmother
Paternal
Grandfather
Maternal
Grandmother
Paternal
Grandfather
Other:
Is there anything else you would like your pediatrician to know about your child?
Patient/ Parent/ Personal Representative Name:
Relationship to Patient:
Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: