NEW PATIENT MEDICAL HISTORY FORM
3603 Davis Drive
Suite C-201
Morrisville, NC 27560
Phone (919) 234-1582
Fax (919) 234-1586 www.buildingblockspediatricsnc.com
Please fill in the forms and bring them with you to your appointment along with your ID and insurance card.
Date: Chart Number: Date of Birth:
First Name:
Gender: male
Middle Name: female E-mail:
Home Phone: Mobile Phone:
How did you learn about Building Blocks Pediatrics, PLLC?
Last Name:
What medicines does your child take? Please include prescriptions, supplements, and over-thecounter medicines that are taken regularly.
Medication Dosage Times Per Day Prescribed By
ALLERGIES
Is your child allergic to any medications? yes
If yes, please list medication and type(s) of reactions(s)
Does your child have any environmental or food allergies?
If yes, please list allergen and type(s) of reactions(s) no yes no
Is your child allergic to eggs?
If yes, please list the type of reaction yes no
Has a physician or other healthcare provider ever prescribed epinephrine (Epi-Pen or Auvi-Q) for severe allergic reaction(s)? yes no

PAST MEDICAL HISTORY
Please indicate if your child currently has or has ever had any of the following illnesses or conditions.
YES NO
Attention Deficit/Hyperactivity Disorder (ADD or ADHD)
Asthma
Behavioral Problems
Recurrent or Frequent Ear Infections
Heart Murmur
Recurrent or Frequent Strep Throat
Urinary Tract Infections
Frequent Wheezing or Coughing Spells
Need to See Another Doctor or Specialist
Does your child have any other significant medical conditions?
If yes, please describe: yes no
Has your child ever been hospitalized?
If yes, when and for what reason(s)? yes no
Has your child had any of the following surgeries?
Ear Tubes Tonsillectomy/Adenoidectomy
Has your child had any other type of surgery?
If yes, when and for what reason? yes
Has your child ever had a serious injury? yes
If yes, what was the injury and when did it occur? no no yes Has your child every had a serious reaction to immunizations?
If yes, what was the reaction and when did it occur?
Was your child born prematurely or were there complications at birth? yes
If yes, please describe:
Appendectomy no no

PREGNANCY AND BIRTH HISTORY (FILL OUT ONLY IF CHILD IS YOUNGER THAN 6 MONTHS )
How many weeks pregnant was the mother when the child was born?
Was the mother Group B Strep positive? yes no
How many hours prior to deliver did the mother ’s membranes rupture? unknown
Were there any complications with the pregnancy or delivery yes no
If yes, please explain:
Was the mother on any medications other than pre-natal vitamins? no yes
If yes, please list:
If C-section, reason:
Name of Hospital:
Type of Delivery: C-Section Vaginal
City and State of birth hospital, if not local:
At birth, what was the baby ’s weight?
Was your child in the breech position at any time during the pregnancy?
Was/is your baby: bottle fed breast fed both
Did your child have a hearing screen at birth?
If yes, were the results Normal yes
Abnormal no yes no
Please list all medical facilities and physician offices at which your baby has received prior care:
Name of Person Completing Form:
Relationship to Child: