pediatric medical history form - HealthFirst Family Care Center

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PEDIATRIC MEDICAL HISTORY FORM
Healthfirst Family Care Center
387 Quarry Street Suite 100
Fall River, MA 02723
508-679-8111
Name:_______________________________________
Date of birth:_________________Age:____________
□Male
Date:__________________________________
Household
□Female
Please list all those living in the child's home.
Name
Relationship
To Child
Birth Date
Health Problems
Are there siblings not listed? If so, please list their
names, ages, and where they live.
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
If mother and father are not living together or if child
does not live with parents, what is the child's custody
status?______________________________________
___________________________________________
___________________________________________
If one or both parents are not living in the home, how
often does he/she see the parent/parents not living in
the home?___________________________________
___________________________________________
___________________________________________
Birth History
Birth Weight ________________________Was the delivery □Vaginal □Cesarean If cesarean, why?________________
Was the baby born at □term □Early □Late If early, how many weeks gestation? ________________________
Did your baby have any problems right after birth? □No □Yes Explain________________________________
Did mother have any illness or problem with her pregnancy? □No □ Yes explain__________________________
During pregnancy, did mother: Smoke: □NO □Yes
Drink alcohol: □NO □Yes
Use drugs or medication: □NO □Yes
What_____________________________When____________________
Was your baby's initial feeding □Breast □Bottle
Did your baby go home with mother from the hospital? □No □ Yes explain_______________________________
General
Do you consider your child to be in good health? □No □Yes Explain___________________________________
Does your child have any serious illness or medical condition? □No □Yes Explain_________________________
Has your child had serious injuries or accidents? □No □Yes Explain___________________________________
Has your child had any surgeries? □No □Yes Explain_______________________________________________
Has your child ever been hospitalized? □No □Yes Explain___________________________________________
Is your child allergic to any medications or drugs? □No □Yes Explain_________________________________
Development
Are you concerned about your child's physical development? □No □Yes Explain_________________________
Are you concerned about your child's mental or emotional development? □No □Yes Explain________________
Are you concerned about your child's attention span? □No □Yes Explain_______________________________
If your child is in school: How is his/her behavior in school?__________________________________________
Has he/she failed or repeated a grade in school? □No □Yes
How is he/she doing in academic subjects? ________________________________________________________
Is he/she in special or resource classes? □No □Yes Explain___________________________________________
Family History
Have any family members had the following:
Deafness
□No □Yes Who_________________Comments_______________________
Nasal allergies
□No □Yes Who_________________Comments_______________________
Asthma
□No □Yes Who_________________Comments_______________________
Tuberculosis
□No □Yes Who_________________Comments_______________________
Heart Disease(before age 50)
□No □Yes Who_________________Comments_______________________
High Blood Pressure(before age 50) □No □Yes Who_________________Comments______________________
High Cholesterol
□No □Yes Who_________________Comments_______________________
Anemia or Bleeding Disorder
□No □Yes Who_________________Comments_______________________
Liver Disease
□No □Yes Who_________________Comments_______________________
Diabetes (before age 50)
□No □Yes Who_________________Comments_______________________
Bed-wetting (after age 10)
□No □Yes Who_________________Comments_______________________
Epilepsy or convulsions
□No □Yes Who_________________Comments_______________________
Alcohol Abuse
□No □Yes Who_________________Comments_______________________
Drug Abuse
□No □Yes Who_________________Comments_______________________
Mental Illness
□No □Yes Who_________________Comments_______________________
Mental Retardation
□No □Yes Who_________________Comments_______________________
Immune problems, HIV or AIDS □No □Yes Who_________________Comments_______________________
Cancer
□No □Yes Who_________________Type:___________________________
Additional family history:______________________________________________________________________
Past History
Does your child have, or has he/she ever had:
Chickenpox
□No □Yes Comments__________________________________
Frequent ear infections
□No □Yes Comments__________________________________
Problems with ears or hearing
□No □Yes Comments__________________________________
Nasal allergies
□No □Yes Comments__________________________________
Problems with eyes or vision
□No □Yes Comments__________________________________
Asthma, bronchitis, bronchiolitis, pneumonia □No □Yes Comments__________________________________
Heart problem or heart murmur
□No □Yes Comments__________________________________
Anemia or bleeding problem
□No □Yes Comments__________________________________
Blood transfusion
□No □Yes Comments__________________________________
Frequent abdominal pain
□No □Yes Comments__________________________________
Constipation requiring doctor visits
□No □Yes Comments__________________________________
Bladder or kidney infection
□No □Yes Comments__________________________________
Bed-wetting (after age 5)
□No □Yes Comments__________________________________
(For girls) Has started menstruation
□No □Yes Comments__________________________________
(For girls) Problems with her period
□No □Yes Comments__________________________________
Any chronic or recurrent skin problem
□No □Yes Comments__________________________________
Frequent headaches
□No □Yes Comments__________________________________
Convulsions or other neurologic problems
□No □Yes Comments__________________________________
Diabetes
□No □Yes Comments__________________________________
Thyroid or endocrine problem
□No □Yes Comments__________________________________
Use of alcohol or drugs
□No □Yes Comments__________________________________
Any other significant problem __________________________________________________________________
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