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:
PREGNANCY & BIRTH HISTORY
1. Did mother have any illnesses or problems during pregnancy?
2. Did mother take any drugs or medications during pregnancy other than iron or Vitamins?
a. If yes, what
3. Did mother drink ANY form of alcohol during pregnancy?
4. Were there any ABNORMAL tests during pregnancy (blood tests, ultrasounds, etc.)
5. Did the baby arrive
a. If late how many days or weeks
6. Were there any problems at the delivery?
7. Did the baby have any problems (breathing problems, jaundice, cyanosis, etc)
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?
10. Does your child usually have more than five (5) colds or sore throats each year
11. Does your child usually get an ear infection after a cold
12. Does your child seem to have a continuous “stuffy” nose or constant cold
13. Has your child had “asthma” or “wheezing” more than two (2) times
14. Has your child had any feeding or gastrointestinal problems
15. Has your child had any problems with urination or urinary tract (kidney) infections
16. Has your child had any heart problems
a. If yes what problems
17. Has your child ever had a convulsion or seizure
18. Has your child had any visual or eye problems
19. Has your child had any ALLERGIC REACTIONS TO MEDICATIONS
If yes what reaction/medication
20. Have any of your children died
21. Has your child ever been hospitalized or had any surgery
a. If yes for what
21. Has your child ever been hospitalized or had any surgery
22. Does your child have any other medical or psychological problems that we should know about
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

Rows	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

Rows	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

Other
Who Lives At Home With The Child
Parent Signature
Date

MonthDayYear
Date
Should be Empty:

Patient History Form

PREGNANCY & BIRTH HISTORY

PATIENT’S PAST HISTORY

FAMILY HISTORY