Family Medical History (Individual)

  • Family Medical History

    Bloom Pediatrics • 2055 E 14 Mile Road, Birmingham, MI 48009 • (248) 645-1740

  • Patients

    List the name and date of birth for each child in your family who is a patient.

  • Patient 1 Date of Birth*
     - -
  • Patient 2 Date of Birth
     - -
  • Patient 3 Date of Birth
     - -
  • Patient 4 Date of Birth
     - -
  • Patient 5 Date of Birth
     - -
  • Patient 6 Date of Birth
     - -

  • Does your child or any of your child's biological parents, siblings, or grandparents have the following conditions for which they are followed by a doctor or treated with medications regularly? Please check all that apply.

  • Conditions

  • For each selected condition, list the biological relatives with the condition and provide any additional details.

    If you select "Patient or Sibling", please specify the person's name in the Details/Comments field.

  • ADHD*
  • Allergies*
  • Anemia*
  • Asthma*
  • Arthritis or Autoimmune Disease*
  • Autism or Developmental Disability*
  • Bedwetting After 7 Years Old*
  • Bleeding or Clotting Disorders*
  • Cancer*
  • Childhood Hearing Loss/Deafness*
  • Colitis (Crohn’s, Ulcerative Colitis, Celiac Disease)*
  • Depression, Anxiety, or Other Mental Illness*
  • Dental Decay or Significant Cavities*
  • Diabetes*
  • Drug/Alcohol Abuse*
  • Eczema/Skin Disorders*
  • Epilepsy or Seizures*
  • Heart Disease Before 55 Years Old*
  • High Blood Pressure*
  • High Cholesterol*
  • Hip Dysplasia*
  • Kidney Disease*
  • Lazy Eye/Strabismus*
  • Learning Disability*
  • Liver Disease*
  • Migraine Headaches*
  • Neurologic Disorders (Seizures, Multiple Sclerosis, Other)*
  • Obesity*
  • Stroke Before 55 Years Old*
  • Sudden Death Before 55 Years Old*
  • Suicide*
  • Thyroid Disorders*
  • Tobacco Use/Vaping*
  • Tuberculosis*
  • Should be Empty: