Family Medical History
ABC Pediatrics • 5333 W. University Drive, McKinney, TX 75071 • (972) 569-9904
Patients
List the name and date of birth for each child in your family who is a patient.
How many children in the family are patients?
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Please Select
One
Two
Three
Four
Five
Six
Patient 1 Name
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Patient 1 Date of Birth
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Month
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Day
Year
Date
Patient 2 Name
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Patient 2 Date of Birth
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Month
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Day
Year
Date
Patient 3 Name
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Patient 3 Date of Birth
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Month
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Day
Year
Date
Patient 4 Name
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Patient 4 Date of Birth
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Month
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Day
Year
Date
Patient 5 Name
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Patient 5 Date of Birth
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Month
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Day
Year
Date
Patient 6 Name
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Patient 6 Date of Birth
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Month
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Day
Year
Date
Conditions
Does your child or any of your child's biological parents, siblings, or grandparents have the following conditions for which they are followed by a doctor or treated with medications regularly? Please check all that apply.
Conditions
Allergies
Asthma
Arthritis or Autoimmune Disease
Autism or Developmental Disability
Bleeding or Clotting Disorders
Cancer
Childhood Hearing Loss/Deafness
Colitis (Crohn’s, Ulcerative Colitis, Celiac Disease)
Depression, Anxiety, or Other Mental Illness
Dental Decay or Significant Cavities
Diabetes
Drug/Alcohol Abuse
Epilepsy or Seizures
Heart Disease Before 55 Years Old
High Blood Pressure
High Cholesterol
Hip Dysplasia
Kidney Disease
Migraine Headaches
Neurologic Disorders (Seizures, Multiple Sclerosis, Other)
Stroke before 55 years old
Sudden Death Before 55 Years Old
Suicide
Thyroid Disorders
Tuberculosis
Condition Details
For each selected condition, list the biological relatives with the condition and provide any additional details. If you select "Patient or Sibling", please specify the person's name in the Details/Comments field.
Allergies
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
*
List known allergies here (medications, foods, hay fever, etc)
Asthma
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Arthritis or Autoimmune Disease
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Autism or Developmental Disability
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Bleeding or Clotting Disorders
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Cancer
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
*
Please specify the type of cancer
Childhood Hearing Loss/Deafness
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Colitis (Crohn’s, Ulcerative Colitis, Celiac Disease)
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
*
Please specify the type of disease
Depression, Anxiety, or Other Mental Illness
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
*
Please specify the type of mental illness
Dental Decay or Significant Cavities
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Diabetes
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
*
Please specify adult or child onset
Drug/Alcohol Abuse
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Epilepsy or Seizures
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Heart Disease Before 55 Years Old
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
High Blood Pressure
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
High Cholesterol
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Hip Dysplasia
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Kidney Disease
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Migraine Headaches
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Neurologic Disorders (Seizures, Multiple Sclerosis, Other)
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
*
Please specify the type of disease
Stroke Before 55 Years Old
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Sudden Death Before 55 Years Old
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Suicide
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Thyroid Disorders
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Tuberculosis
*
Patient or Sibling
Mother
Father
Maternal Grandparent
Paternal Grandparent
Details/Comments
Form completed by:
Printed Name
*
Relationship to Patient
*
Date
*
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Month
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Day
Year
Date
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