Patient History Form
Patient Name:
Date of Birth:
-
Month
-
Day
Year
Date
Birth Weight:
lbs & oz
Delivery:
Vaginal
Cesarean Section
PREGNANCY & BIRTH HISTORY
1. Did mother have any illnesses or problems during pregnancy?
Yes
No
List all illnesses:
2. Did mother take any drugs or medications during pregnancy other than iron or Vitamins?
Yes
No
If yes, what
3. Did mother drink
ANY
form of alcohol during pregnancy?
Yes
No
4. Were there any
ABNORMAL
tests during pregnancy (blood tests, ultrasounds, etc.)?
Yes
No
List tests:
5. How many weeks long was the pregnancy?
6. Were there any problems at the delivery?
Yes
No
7. Did the baby have any problems (breathing problems, jaundice, cyanosis, etc)?
Yes
No
If yes, explain
PATIENT’S PAST HISTORY
8. At what age did your child
ROLL OVER
SIT
STAND
WALK
START TALKING
TOILET TRAINED
9. Has your child had more than four (4) ear infections in the past year?
Yes
No
10. Does your child usually have more than five (5) colds or sore throats each year?
Yes
No
11. Does your child usually get an ear infection after a cold?
Yes
No
12. Does your child seem to have a continuous “stuffy” nose or constant cold?
Yes
No
13. Has your child had “asthma” or “wheezing” more than two (2) times?
Yes
No
14. Has your child had any feeding or gastrointestinal problems?
Yes
No
15. Has your child had any problems with urination or urinary tract (kidney) infections?
Yes
No
16. Has your child had any heart problems?
Yes
No
If yes what problems?
17. Has your child ever had a convulsion or seizure?
Yes
No
18. Has your child had any visual or eye problems?
Yes
No
19. Has your child had any
ALLERGIC REACTIONS TO MEDICATIONS
?
Yes
No
If yes what reaction/medication?
20. Have any of your children died?
Yes
No
21. Has your child ever been hospitalized or had any surgery?
Yes
No
If yes for what
22. Does your child have any other medical or psychological problems that we should know about?
Yes
No
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
Anemia
Bleeding Problems
Migraines
Asthma
Allergies/Hay Fever
Eczema
Cystic Fibrosis
Lupus
Tuberculosis (TB)
Alcohol Problems
Drug Problems
Mental Health Problems
Seizures/Epilepsy
Kidney Prob (& Infection)
Lazy Eye
Rheumatoid Arthritis
Other
Mark 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
Mental Health
High Triglyceride
Type 1 or 2 Diabetes
Mother’s Age
Father’s Age
Please Select One
Married
Divorced
Other
Who Lives At Home With The Child
Parent Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: