Katz Pediatrics
Pediatric Health History Form – Initial Visit
Child’s Name ______________________DOB ____________ Age______ Today’s Date_______________
Child’s Past Medical History
Pregnancy/Neonatal Period
Where was your child born? _______________________
Is the child yours by ☐birth ☐adoption ☐stepchild ☐other
Delivery: ☐vaginal ☐C-section
Was your child premature? ☐No ☐Yes, born at ___weeks
Birth Weight ___________
Problems in the newborn period
__________________________________________________
__________________________________________________
Infancy/Childhood/Adolescence
Has your child ever been treated or diagnosed with (explain)
☐Asthma or reactive airway disease _________________________
☐Wheezing or bronchiolitis ________________________________
☐Seasonal Allergies _______________________________________
☐Eczema _______________________________________________
☐Food Allergy ___________________________________________
☐Recurrent ear infections __________________________________
☐Pneumonia ____________________________________________
☐Urinary Tract Infections __________________________________
☐Seizures _______________________________________________
☐Anemia _______________________________________________
☐Broken Bone ___________________________________________
☐Depression/Anxiety _____________________________________
☐Heart Murmur _________________________________________
☐Constipation ___________________________________________
☐Chicken Pox ___________________________________________
☐Attention Deficit Disorder ________________________________
☐Other chronic medical
conditions_______________________________________________
________________________________________________
Has your child ever been hospitalized? ☐No
☐Yes (explain)
________________________________________________________
________________________________________________________
________________________________________________________
Past surgeries or
procedures?______________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Please list any specialist your child has seen, dates, and
reason:__________________________________________________
__________________________________________________
__________________________________________________
Medications
Please list ALLERGIES to medicine
________________________________________________________
________________________________________________________
Current Medications
________________________________________________________
________________________________________________________
Any concerns about your child’s
development/nutrition?____________________________________
________________________________________________________
________________________________________________________
Name of School or Daycare ☐NONE __________________________
Social History
Who lives in the child’s household? ☐Mom ☐Dad ☐Step________
☐siblings (#_____) ☐Grandparents ☐Other ___________________
Childs Parents are ☐married ☐unmarried ☐divorced ☐other
Moms Occupation ______________ Dads Occupation____________
Do any household members smoke? ☐Yes ☐No
Family History
Do any family members have any of the following conditions?
Condition
Mother Father Sibling Grandparent
Asthma
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Allergies
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Anemia
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Blood Disorder
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Cancer
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High Cholesterol ☐
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High blood pressure☐
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Heart attack/disease☐
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Diabetes
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Thyroid Disease
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Kidney Disease
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Seizures
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Migraines
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Autism
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Depression/anxiety☐
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Alcoholism
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ADD/ADHD
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Other Issues:
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_____________
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Please explain all
positives:________________________________________________
________________________________________________________
________________________________________________________
Katz Pediatrics
Pediatric Health History Form – Initial Visit
Child’s Name ______________________DOB ____________ Age______ Today’s Date_______________