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 __________________________________________________________________