PEDS Med History Form

Today's Date*

Date

Patient Name*

First NameLast Name

Date of Birth*

Date

Email

example@example.com

Name of Referring Pediatrician (enter "None" if you do not have a referring pediatrician):*

Please list any other referring provider you would like us to send your visit notes to:

Ethnicity

Sex Assigned at Birth*

MaleFemale

Pronouns (Optional)

What is your main concern you would like to discuss with the doctor? (Be specific) *

List ALL skin medications and over the counter products you are currently using / have used for this condition.

Do you have a history of any specific skin disease?*

NoYes

If yes, please explain.

Do you have any changing moles?*

NoYes

If yes, where?

Are you allergic to any medications?*

NoYesUnknown

If yes, please list them here.

Please list any medications you are currently taking, including over-the-counter, vitamins, and herbs.

List any surgical procedures/hospitalizations you have had and the years.

Please check the box(es) for any diseases or conditions you currently have or have had in the past.*

Seasonal allergiesAsthmaDepression / AnxietyInflammatory Bowel DiseaseGenetic DisordersI do not currently have any of the above conditions nor have I had any of these conditions in the past

If you checked any diseases/conditions above, please explain here.

List any other conditions you currently have or have had.

Please carefully review this symptom list:

General: weight change, change in energy, change in strength or exercise
tolerance

Head: headaches, vertigo, head injury

Eyes: change in vision, seeing double, tearing, partial vision loss, eye pain Ears:
change in hearing, ringing, bleeding, vertigo/dizziness Nose: bleeding noses, running nose, obstruction, discharge

Mouth: dental difficulties, gingival bleeding, use of dentures

Neck: stiffness, pain, tenderness, masses

Breast: lumps, tenderness, swelling, nipple discharge

Chest: shortness of breath, wheezing, coughing up blood, chronic coughing

Heart: chest pains, palpitations, syncope

Abdomen: change in appetite, trouble swallowing, abdominal pains, bowel habit
changes, blood in your stool

GU: urinary urgency, pain with urinating, change in nature of urine

Women Gyn: change in menses, pain with menses, vaginal discharge, pelvic pain

Musculoskeletal: pain in muscles or joints, limitation of range of motion, numbness

Neurologic: weakness, tremor, seizures, changes in mentation, lack of coordination

Psychiatric: depressive symptoms, changes in sleep habits, changes in thought content

Other: excessive sweating

Are you experiencing any of the symptoms listed above?*

NoYes

If yes, please indicate symptoms here.

School Grade:

Hobbies:

Were you full term?*

NoYes

Were there any complications during your mother's pregnancy or your birth?*

NoYes

Do you currently or have you ever smoked / vaped?*

NoYes, quitYes, current

If current, how much do you smoke or vape per day?

Do you use alcohol?*

NoYes

Do you use drugs?*

NoYes

If yes, please explain.

Females, if you've started your period, what age were you?

Are your periods regular?

NoYes

Please check any of the below diseases that run in your family.

When you are exposed to sun, do you:*

Tan onlyTan and burnBurn only

Do you wear sunscreen?*

No, neverYes, sometimes when I'm outsideYes, always when I'm outsideYes, daily

Have you ever used a tanning bed?*

No, neverYes, in the pastYes, currently

Preferred Pharmacy*

If you selected Other above, please list your pharmacy here.

Please attach a copy or picture of your photo ID.

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Please attach a copy or picture of the front side of your insurance card.

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Please attach a copy or picture of the back side of your insurance card.

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Please attach a copy or picture of the front side of your pharmacy card.

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Please attach a copy or picture of the back side of your pharmacy card.

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Pediatric Medical History Form