Patient Health History
Please complete this form for each patient.
Name
*
First Name
Middle Name
Last Name
Preferred Name/Nickname/Pronouns (if applicable)
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Race
*
White
Black or African American
Asian
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
Prefers not to answer
Other
Ethnicity
*
Hispanic or Latino
Not Hispanic nor Latino
Prefers not to answer
Preferred Language
*
English
Spanish
Prefers not to answer
Other
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Newborns and Children Under 1 Year of Age
Gestational Age
Full-Term
Premature
If Preterm, how many weeks?
Birth Hospital
Sacred Heart
Holy Family
Deaconess
Valley
Other (list below)
Hospital (if not listed above)
Birth Weight (in pounds and ounces)
Any issues during pregnancy including abnormal screenings?
Yes (please explain below)
No
Issues or abnormal screenings during pregnancy
Any issues after delivery?
Yes (please explain below)
No
Issues after delivery
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Medication Information
Preferred Pharmacy
Current Medications (including over-the-counter or herbal supplements)
If your child does not take any medications, please check below.
No Medications
Allergies
If your child has no known allergies, please check below.
No Allergies Known
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Medical History
Current or Previous Medical Conditions
ADHD
Adoption/Foster Care
Allergies
Anxiety
Asthma/Wheezing
Behavior Concerns
Cancer
Depression
Developmental Concerns
Diabetes
Ear Infections (recurrent)
Eczema
Genetic Condition
Headaches/Migraines
Heart Conditions
Prematurity
Reflux
Seizures
Urinary Issues
Other
Please briefly describe any conditions marked above.
Past Surgical History
Adenoidectomy
Circumcision
Ear Tubes
Tonsillectomy
Other
Please indicate the approximate date of the above surgeries and include any additional surgeries indicated by "Other."
Family Medical History: Please indicate any family history of the following conditions. If a condition is not listed, please describe this below.
Rows
Yes
Which Family Member(s)
Additional Information
ADHD
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Adopted
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Allergies
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Anxiety
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Asthma
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Cancer
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Depression
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Developmental Delay
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Diabetes
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Genetic Issues
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Heart Disease
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
High Blood Pressure
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Mental Health
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Substance Abuse
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Thyroid Issues
Mother
Father
Sister
Brother
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Other
Any other medical issues that run in the patient's family?
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Social History
Who lives in the home with the child? If parents are separated, please indicate who resides at each home and the current time spent at each residence.
Does your child attend daycare/school?
Yes
No
If yes, where and what grade?
Do you have pets in the home?
Yes
No
If yes, what type?
Does your child have any secondhand smoke exposure (including vaping and marijuana)?
Yes
No
Is there a history of abuse, neglect or CPS involvement?
Yes
No
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Additional Part of the Patient's Care Team
If your child sees a dentist, who does he/she see?
Children's Choice
South Hill Pediatric Dentistry
KidSmile (Dr. Blake and Dr. Ryan)
Children's Dental Village
Dr. Molly Gunsaulis
Moffitt Children's Dentistry
KiDDS Dental (Dr. Jared Evans)
The Kidds Place (Dr. Luchini)
Other
Does your child see any other medical professionals or therapists? If so, please list them below.
Submit
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