oviedokids.com - New Patient History

Patient History Form

OVIEDO CHILDREN’S HEALTH CENTER
Patient Name:
Date of Birth:

MonthDayYear
Date
Birth Weight: lbs oz
Delivery:

VaginalCesarean Section
PREGNANCY & BIRTH HISTORY
1. Did mother have any illnesses or problems during pregnancy?

YesNo
2. Did mother take any drugs or medications during pregnancy other than iron or Vitamins?

YesNo
a. If yes, what
3. Did mother drink ANY form of alcohol during pregnancy?

YesNo
4. Were there any ABNORMAL tests during pregnancy (blood tests, ultrasounds, etc.)

YesNo
5. Did the baby arrive

EarlyLate
a. If late how many days or weeks
6. Were there any problems at the delivery?

YesNo
7. Did the baby have any problems (breathing problems, jaundice, cyanosis, etc)

YesNo
a. If yes, explain
PATIENT’S PAST HISTORY
8. At what age did your child
ROLL OVER: Enter Age SIT: Enter Age STAND: Enter Age
WALK: Enter Age START TALKING: Enter Age TOILET TRAINED: Enter Age
9. Has your child had more than four (4) ear infections?

YesNo
10. Does your child usually have more than five (5) colds or sore throats each year

YesNo
11. Does your child usually get an ear infection after a cold

YesNo
12. Does your child seem to have a continuous “stuffy” nose or constant cold

YesNo
13. Has your child had “asthma” or “wheezing” more than two (2) times

YesNo
14. Has your child had any feeding or gastrointestinal problems

YesNo
15. Has your child had any problems with urination or urinary tract (kidney) infections

YesNo
16. Has your child had any heart problems

YesNo
a. If yes what problems
17. Has your child ever had a convulsion or seizure

YesNo
18. Has your child had any visual or eye problems

YesNo
19. Has your child had any ALLERGIC REACTIONS TO MEDICATIONS

YesNo
If yes what reaction/medication
20. Have any of your children died

YesNo
21. Has your child ever been hospitalized or had any surgery

YesNo
a. If yes for what
21. Has your child ever been hospitalized or had any surgery

YesNo
22. Does your child have any other medical or psychological problems that we should know about

YesNo
a. If yes explain
FAMILY HISTORY

Please list any family members that have the following problems; include parents, grandparents, aunts, uncles, and cousins. ANSWER AS IF ANSWERING FOR YOUR CHILD

	Family Members
AIDS (+HIV Test)
Depression
Thyroid Problems
Diabetes
Cancer/Leukemia
Crib Death (SIDS)
Sinus Problems
Inherited Disorders
Sickle Cell Anemia (or Trait)
Early Deafness
Tuberculosis (TB)
Anemia
Alcohol Problems
Bleeding Problems
Drug Problems
Migraines
Psychiatric Problems
Asthma
Seizures/Epilepsy
Allergies/Hay Fever
Kidney Prob (& Infection)
Eczema
Lazy Eye
Cystic Fibrosis
Rheumatoid Arthritis
Lupus
Other

Check in the box to all that apply

	Mother	Father	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather	Sibling 1	Sibling 2
Obesity
Cardiovascular Disease
High Blood Pressure
Stroke
High Cholesterol
High Triglyceride
Type 1 or 2 Diabetes

Mother’s Age
Father’s Age
Please Select One

MarriedDivorcedOther
Who Lives At Home With The Child
Parent Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Patient History Form

PREGNANCY & BIRTH HISTORY

PATIENT’S PAST HISTORY

FAMILY HISTORY