Medical History Information

Medical History Information
Patient Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Name/Nickname
Allergies
Current Medications
Please list any hospitalizations including reasons and age
Please list any surgeries including reasons and age
Please list any poisonings including reasons and age
Please list any injuries including reasons and age
Birth History
Birth Weight
Weeks Gestation
Caesarian Section (yes or no)
Adopted?
Complications during pregnancy (bleeding, infection, medications, exposure to x-ray, hypertension, gestational diabetes...)
Complications during delivery (preterm labor, delay in breathing...)
Treatment for Jaundice?
City Water or Well Water?
Breastmilk or Formula?
Social History
Who does the patient primarily live with?
Father's Age
Father's Occupation
Mother's Age
Mother's Occupation
Parents are:
Any custody issues
Legal Guardians
Siblings name and ages if any:
Smokers in the household?
Pets
Developmental History
Have there ever been any developmental concerns
If female. Have menstrual periods begun? Y or N
If yes, at what age
Vaccination History
Are immunizations up to date?
Patient Name
DOB

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