Pediatric Medical History Form

We hope you will answer the questions on this medical history form as thoughtfully as possible. Many of the questions that follow may not seem directly related to your main complaint or reason for seeking care. However, the answers to these questions, as well as the information you provide in the office, will determine the individualized approach taken to begin your treatment. Please consider this an opportunity to write anything you think may be pertinent to your health that you may not have spoken with any other provider in the past. ALL THE INFORMATION IN THIS QUESTIONNAIRE IS CONFIDENTIAL BY LAW.

Today's Date *

Date

What is patient's name? *

First Name Last name

Patient's Date of Birth? *

Your date of birth

Patient's Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email address? (Parent's email is ok) *

Email Address

What is your phone number? *

Name of person completing this form?

What is your relationship to patient?

With whom does this child live?

Please include name/relationship of all parents and/or legal guardians

Was this child adopted? If yes, at what age

What is the reason for today's visit? Please include when any problems began?

What have you tried to improve any above problems?

Height

Weight

Usual Weight

Allergies to Medication? Please include what reaction you have.

Allergies to Foods? Include type of testing and symptoms when food ingested

Surgical History? Include dates if you recall

Hospitalizations? Include dates if you recall

Include name, dose, how often you take, and why you take for each item. There is room for 10 items. Please click add more at bottom if you need more space.

Please check all conditions that your child is currently experiencing or has experienced in the past

Family History - Please check any of the following that a family member has experienced:

Vaccine History

	Date #1	Date #2	Date #3	Date #4	Date #5
DTaP
HiB
MMR
Hepatitis A
Hepatitis B
Varicella (Chicken Pox)
Polio
Influenza
Pneumoncoccal

Prenatal History

Please describe any problems with conception or infertility treatment received for this child?

Please check any of the following that applied to the pregnancy:

Please elaborate on any of the above as needed

Maternal age for the prenancy?

Paternal age for the prenancy?

Please indicate the general health/well being of the mother during the pregnancy

Excellent Good Fair Poor Unknown

Please indicate the emotional well being of the mother during the pregnancy

Excellent Good Fair Poor Unknown

Please indicate the general health/well being of the father during the pregnancy

Excellent Good Fair Poor Unknown

Please indicate the emotional well being of the father during the pregnancy

Excellent Good Fair Poor Unknown

Early Childhood History

Where was the birth?

Name of midwife/obstetrician/health care providers?

Gestational Age at Birth in weeks? (For example, 38 weeks 3 days)

Birth Weight and Length?

Please indicate if any of the following interventions occured during labor and birth:

Other? Need to clarify? Please type

Were there any birth complications?

How long was the labor?

APGAR Score (if known) at 1 minute and 5 minutes?

Please indicate if any of the following were present shortly after birth

At What Age did your child first?

	Age?	Comments?
Sit Up?
Crawl?
Walk?
Talk?
Start Teething

Were there any difficulties associated with feeding?

How is the child's behavior at home?

General school/daycare behavior/performance?

Does your child have any habits?

Does your child have any fears?

Has your child been diagnosed with any learning disabilities?

Does your child make friends easily?

Child's interests and favorite activities?

How Many hours/week does your child?

	Hours?	Comments?
Play on the computer or video games?
Exercise?
Watch Television?
Read (not for school)?

Please write a little about your child's personality?

Lifestyle Habits

What time does your child usually go to bed?

Wake up?

Does your child nap during the day and at what time(s)?

Does your child have nightmares and how often?

Does your child have any problems associated with sleeping (trouble falling asleep, grinding teeth, sleep walking, etc?)

Was/Is your child breastfed? For how long?

Was/Is your child formula fed? Which formula?

Please note any problems with or reactions to feeding

When was solid food introduced?

Timing of food introduction (grains, fruits, veggies, etc)?

Describe your child's eating behaviors?

Is the Child exposed to any of the following on a regular basis?

Marital status of the child's parents? If separated or divorced, what is the custody arrangement for the child?

What is the source of your child's drinking water?

Please write any other pertinent information you would like us to know about your child's health?

3 Day Diet History

Please record breakfast, lunch, dinner, and snacks for any 3 days prior to your appointment. Please include drinks. It is not necessary to write amounts of each item. (eg. Simply write peas. Not necessary to write 1/2 cup of peas)

	Day 1	Day 2	Day 3
Breakfast
Lunch
Dinner
Snacks

Please sign your name with attached stylus or mouse if completing at home. All data on this form is encrypted and is transmitted securely via SSL. *