Circle preference
Leave blank if no preference
Michael W. Conway, M.D.
Michael C. Kilpatrick, M.D.
Randall D. Brown, M.D.
David J. Hartung, D.O.
Derek A. Oldham, M.D.
Terri J. Agan, RNC NP-C
Bret A. Cornn, MMSC, PA-C
Rhonda L. Fountain, NP-C
1124 Medical Place
Seymour, Indiana 47274
Tel: 812-522-1613
Fax: 812-522-6694
JACKSON PARK PHYSICIANS
Child Patient Health History Form
Name:
Gender:
Date of Birth:
M
F SSN:
Today’s Date
This child lives with:
Mother
Grandparent/Other
Father
Mother/Father
Mother/Partner
Father/Partner
Other Children in Family:
Date of Birth
Gender
Name
_____________________
__________
_______________________________________
_____________________
__________
_______________________________________
_____________________
__________
_______________________________________
_____________________
__________
_______________________________________
SOCIOECONOMICS Please indicate:
Education
Grade school
High school
College
Graduate school
Use of Alcohol
Never
Rarley
Moderate
Daily
Use of Tobacco
Never
Previously, but quit___________ Current Packs/Daily _________
Have you ever used needles to inject drugs?
No
Yes
PEDIATRIC/CHILD HEALTH HISTORY
Delivery at how many weeks?
Smokers in home?
Yes
No
Immunizations current?
Yes
No
ALLERGIES List all allergies to medications, dyes, other:
None
Latex Allergy
PAST MEDICAL
HISTORY
HAVE YOU EVER HAD ONE OF THE
FOLLOWING: (MARK X)
Measles
Mumps
Chickenpox
Whooping Cough
Small Pox
Pneumonia
Anemia
Bladder Infection
Migraine Headaches
Diabetes
Cancer
Hernia
High Blood Pressure
Low Blood Pressure
Asthma
Hives
Eczema
Any other disease, please list:
MEDICATIONS Prescription, over the counter medicines, vitamins, home remedies, herbs, etc.
Medication
Dose (mg/pill, units, etc)
Frequency (times/day)
(List additional medications on reverse of sheet if necessary. Please bring a current medication list to
each office visit.)
PREVIOUS HOSPITALIZATION/SURGERIES
DATE
HOSPITAL, CITY, STATE
So that Jackson Park Physicians can best serve my medical needs, I have completed this questionnaire as
completely as possible. I understand that the Patient/Health Care Provider relationship is built on trust
and honesty. By completing and signing this form, I acknowledge that any intentionally false
information could seriously affect my health.
Printed Name:
Parent or Legal Guardian :
Date: