Pediatric History Form

Pediatric History Form

Department of Medical Genetic and Genomic Medicine
Please note that information entered into this form is kept highly confidential and is protected under the New Jersey Genetic Privacy Act (P.L. 1996, c.126 (C. 10:5-43 et al.) Once completed, the form is submitted directly to the Department of Medical Genetic and Genomic Medicine at Saint Peter's University Hospital.

Timely return of this form will greatly assist us in scheduling your appointment. Please be as specific as possible when documenting. You will receive an email confirmation with instructions for your next steps. If there are any issues completing this form, please contact us at 732-339-7481.

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Birth History Information
Which pregnancy was this for the mother?
Was the pregnancy a natural conception or were medications/ IVF/ fertility treatments necessary?
How many weeks pregnant was the mother at the time of her first obstetrical visit?
Were there any maternal exposures during pregnancy to medications, illnesses/ fevers, radiation, trauma, cigarettes, alcohol, or other drugs?
Was the pregnancy complicated by a maternal condition for example, diabetes, high blood pressure, seizures or other?
Were there any abnormal prenatal test results? (Ex: maternal serum screening, non-invasive prenatal screening, ultrasound findings)
Were there any invasive procedures(chorionic villus sampling or amniocentesis) performed? If so, what were the results?
At which week of pregnancy was the child delivered?
Birth Type - How was the patient delivered at birth?

Vaginal DeliveryCesarean Section
Birth weight
Birth length
Birth head circumference
Were there any problems with delivery?
How many days was the baby hospitalized before being discharged home?
Were they any feeding difficulties in infancy?
Please upload any photo that is relevant to this appointment if available.

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Please upload any file that is relevant to this appointment if available.

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Medical Information
Please list any medical problems or conditions (and the age of onset) the child has received care for; or is currently receiving medical care for. Select the plus sign to list each condition separately.
Please list the names of any other specialists seen. Including their location. Select the plus sign to list each physician separately.
Please list all surgeries the child has had, the dates and the name of the hospital where they were performed. Select the plus sign to list each surgery on separate lines.
List any other hospitalizations the child has had, excluding those for surgery. Include the hospital, dates and reason for admission. Use the plus sign to list each separately.
List any emergency room visits the child has had (accident, or trauma, etc.), excluding visits in which your child was admitted. Include the hospital, dates and reason for visit. Use the plus sign to list each visit separately.
List all medications and the dosage that the child is currently taking. Use the + sign to list each separately.
List any allergies the child has, especially to medications.
Is the child on a regular diet? Are there any restrictions, foods that are avoided, or special formulas?
Does the child have any difficulty sleeping? If so, please describe.
Does the child have any behavioral problems? If so, please describe.
Has the patient experienced any developmental delays? If so, please describe. (Ex: motor delays, speech)
If the patient is an adolescent female, please list the age at which her menstrual cycles began
Has the child ever received early intervention services, physical therapy, occupational therapy, or speech therapy? If so, please describe the length of time, type of service and who provided the services.
Has the child had any difficulty in school requiring special education or remedial classes/tutoring? If so, please describe.

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Social History
Does the patient attend day care?

YesNo
If school age, what grade is the patient currently in?
How many years of school did the child's mother complete?
If the mother is currently employed, what kind of work does she do?
How many years of school did the patient's father complete?
If the father is currently employed, what kind of work does he do?
Are the child's parents or their families related by blood or anyway other than marriage? If so, describe.
Who does the child live at home with?
Does anyone smoke at home?

YesNo
Are there any pets in the home?

YesNoOther

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Family History
Medical Conditions

First Degree Relatives include the child, parents or siblings. Second Degree Relatives includes grandparents, aunts, uncles and cousins, in relation to the patient. It is important to note for Second Degree Relatives, whether the condition refers to the mother's side (Maternal) versus the father's side (Paternal). Please indicate if the patient or any of their blood relatives have ever had or currently has any of the listed medical conditions, by selecting the appropriate checkboxes. Include half-brothers and sisters, but omit relatives related by marriage or adoption. Select all that apply if the condition exists with multiple family members on both sides. The Additional Note section can be used to free text any further details regarding your selections.
Miscarriages (how many?)
Stillbirths (how many?)
Infant deaths (less than 1yr old)
Infertility
Seizures, Epilepsy
Cerebral Palsy
Brain Abnormality
Spina Bifida
Hydrocephalus
Microcephaly (small head)
Blindness/Vision Problems
Deafness, Hearing Loss
Cleft Lip and/or Cleft Palate
Dental Problems (i.e. extra or missing teeth)
Respiratory Problems (i.e. Asthma)
Born with Heart Defect
Hypertension (high blood pressure)
Heart Attack
Stroke
Pyloric Stenosis
Ulcerative Colitis
Kidney Problems (i.e. Cystic Kidney Disease)
Hip Problems
Scoliosis
Malformed Extremities (i.e. hands, fingers, feet, toes, Club Foot, etc.)
Short Stature or Dwarfism
Arthritis or Joint Problems
Muscular Dystrophy
Muscle Weakness
Multiple Sclerosis
Parkinson's Disease
Birthmarks
Skin Color Differences
Bleeding Problems (Hemophilia)
Sickle Cell Anemia
Thalassemia
Immune Deficiency
Childhood Diabetes
Adult Diabetes
Thyroid Problems
Alzheimer's Disease
Huntington's Disease
Speech Problems
Intellectual or Learning Disability
Autism
Chromosomal Abnormality
Mental Illness (i.e. depression, schizophrenia, bipolar disorder, etc.)
Alcoholism or Other Drug/Chemical Dependency
Weight Problem (Obesity or Anorexia)
Cancer (i.e. Breast, Colon, Ovarian, Prostate, etc.)
Are there any other distant relatives with medical problems not listed above?
Please list any other information you believe to be relevant to your child's referral to our office.

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Consent and Signature
By signing below, I certify that all information submitted is true and correct to the best of my knowledge.
Full legal name of the person completing this form.*

First NameLast Name
Signature*
Relation to patient:*
DateTime
Name of Interpreter if used.

First NameLast Name
Interpreter Signature
DateTime
Should be Empty:

Pediatric History Form

Medical Conditions