THE CENTER FOR PEDIATRIC &
ADOLESCENT MEDICINE
Revised 01/17/05
FAMILY HISTORY
Patient’s Name___________________________________________
Date _______________
FAMILY MEMBER
AGE
LIST ANY HEALTH PROBLEMS
Mother
____
___________________________________
Father
____
___________________________________
Sibling
____
___________________________________
Sibling
____
___________________________________
Sibling
____
___________________________________
Sibling
____
___________________________________
Sibling
____
___________________________________
Sibling
____
___________________________________
List any family member related to the patient who has any of the following diseases
Miscarriages______________ Allergies, Hay fever, Asthma________
Liver Disease_________
Mental Retardation_________ High Cholesterol__________________
Intestinal Disease______
Birth defects______________ Bleeding Disorders________________
Any Other Diseases_____
Seizures__________________ Rheumatic Heart Disease___________
_____________________
Diabetes__________________ Kidney Disease___________________
EXPOSURE
Does anyone in your household smoke, drink alcohol, chew smokeless chewing tobacco, or drugs? Y / N
If yes who? ______________________________________
Does anyone in the household have a gun?
Yes / No
If yes who?_________________________
BIRTH HISTORY
Pregnancy:
Delivery:
Full term
or
Premature ____ Weeks Gestation
Vaginal or C-section
Neonatal Course
Any Complications in the nursery? ______________________________
DIETARY HISTORY
Present Eating Habits:
Infant : Formula Type _________
Solid Foods _______________
Child : Good or Picky Eater
Do you have well water ?
Y or N
DEVELOPMENTAL HISTORY
List age when accomplished each of the following:
INFANT
Sat up alone ______ Said 1st Words ______
______
Said 1st Sentence ______
1st Teeth ______
Walked
Toilet Trained ______
SCHOOL AGE
Present Grade ______
Any Problems _____________________________________________
HOSPITALIZATIONS
List all Hospitalizations, age and diagnosis, not including surgeries
Diagnosis
Age
Diagnosis
Age
_________
______
________
______
_________
______
________
______
SURGERIES
List all surgeries, age and diagnosis
Diagnosis
Age
Diagnosis
Age
_________
______
_________
______
_________
______
_________
______
MAJOR ILLNESSES
List any past major illnesses (i.e. Urinary tract infections, pneumonias, strep throat etc…….)
Diagnosis
Diagnosis
________________________________
_________________________________
________________________________
_________________________________
INJURIES
List all injuries (i.e. Broken bones, skull fractures, or major injuries)
Diagnosis
________________________________
Diagnosis
_________________________________
________________________________
_________________________________
MEDICATIONS
Please list all current medications your child is taking
__________________________________________________________________________________
__________________________________________________________________________________
ALLERGIES TO ANY MEDICATIONS
List all medications to which your child is allergic to
__________________________________________________________________________________
__________________________________________________________________________________
UPDATED ( Every 2 Years)
1)__________ 2)__________ 3)__________ 4)__________ 5)__________
6)__________ 7)__________ 8)__________ 9)__________ 10)_________
PATIENT’S NAME____________________________________________ DOB_________________
Revised 01/17/2005
IMMUNIZATIONS
This section to be completed by the nurse or physician
DTAP/TD
Pediarix
1) ________
1) ________
1) ________
1) ________
1) ________
1) ________
2) ________
2) ________
2) ________
2) ________
2) ________
2) ________
3) ________
3) ________
3) ________
3) ________
3) ________
4) ________
4) ________
4) ________
5) ________
5) ________
Varivax
Prevnar 7
IPV
Hib
1)________
1)________
1)________
1)________
2)________
2)________
2)________
2)________
2)________
4) ________
MMR
4) ________
Pnu-23
Immune
1)________
3) ________
HEP A
HBV
Td Booster
Menomune
1)________