Pediatric Health History Form
Child’s Name: Click here to enter text.
Age: Click here to enter text. Gender: Choose an item.
Date of birth: Click here to enter a date. Place of birth: Click here to enter text.
Ethnic Background: Click here to enter text.
Name of parent(s)/guardian(s): Click here to enter text.
Address: Click here to enter text.
Phone: Click here to enter text.(home)
Click here to enter text.
Click here to enter text. (work)
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Click here to enter text. (other)
Email: Click here to enter text.
Is the child adopted? Choose an item.
If yes, when? Click here to enter text.
Are parents: Choose an item. Who does the child live with? Click here to enter text.
Child’s primary care physician / pediatrician: Click here to enter text.
Address: Click here to enter text.
Phone:Click here to enter text. Can we contact this doctor? Choose an item.
Emergency Contact (Name & Phone Number): Click here to enter text.
How did you hear about our office? Choose an item.
Please list the health concerns of the child in order of importance:
1.Click here to enter text.
2.Click here to enter text.
3.Click here to enter text.
Medical History
4.Click here to enter text.
5.Click here to enter text.
6.Click here to enter text.
Please describe any serious conditions, hospitalizations, operations, illnesses or injuries with
their dates: Click here to enter text.
Please list all current medications the child is taking (i.e. prescription, over-the-counter, etc):
Click here to enter text.
Please list all vitamins, herbs, homeopathics or other supplements the child is taking: Click here to
enter text.
1
Please list any medication your child has taken for an extended period of time: Click here to enter
text.
Has your child ever taken antibiotics? Choose an item. If yes, for what condition? Click here to
enter text.
Does your child have any allergies (environmental, medication, seasonal, etc.)? Describe.
Click here to enter text.
Please indicate if the child has recently been tested for the following:
Condition
Hearing
Yearly
physical
Speech
Yes / No
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When?
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Condition
Vision
Dental
Blood Tests
Yes / No
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item.
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item.
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item.
When?
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Please circle if your child has experience any of the following conditions currently (C) or in the
past (P) – you may circle both if applicable:
Strep Throat
Chicken Pox
Measles
Rubella
Mononucleosis
Mumps
Roseola
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an
item.
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an
item.
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an
item.
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an
item.
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an
item.
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an
item.
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an
item.
Asthma
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an item.
Hives/Rashes
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item.
Bronchitis
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an item.
Eczema
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item.
Allergies
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an item.
Herpes (Oral)
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item.
Itchy Eyes
Choose
an item.
Bruises Easily
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item.
Chronic Colds
Choose
an item.
Bad Breath
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item.
Sinus Troubles
Choose
an item.
Fainting
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item.
Ear Infections
Choose
an item.
Seizures
Choose an
item.
Choose Recurring Fevers
an
item.
Influenza
Choose Constipation
an
item.
Scarlet Fever
Choose Diarrhea
an
item.
Impetigo
Choose Digestive Problems
an
item.
Pneumonia
Choose Colic
an
item.
Other: Click here to enter text.
Whooping
Cough
Choose
an item.
Headaches
Choose an
item.
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an item.
Temper Tantrums
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item.
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an item.
Bed Wetting
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item.
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an item.
Nail Biting
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item.
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an item.
Depression
Anxiety
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item.
Family History
Any Medical Conditions?
Mother
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Maternal
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Grandmother
Are they still
living?
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item.
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item.
If not, cause of
death?
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text.
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text.
Age
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enter text.
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enter text.
Maternal
Grandfather
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Choose an
item.
Click here to enter
text.
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enter text.
Father
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item.
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item.
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text.
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text.
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item.
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text.
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Paternal
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Grandmother
Paternal
Grandfather
Siblings:
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item.
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text.
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Immunizations
Has your child received regular vaccinations according to the standard Pediatric schedule?
Choose an item. If no, please explain: Click here to enter text.
If known, please indicated which of the following vaccinations your child has had:
☐ DPT (diphtheria,
pertussis, tetan
☐ HiB (Haemophilus,
influenza B)
☐ Hepatitis A
☐ Tetanus booster
☐ Polio
☐ Hepatitis B
☐ MMR (measles,
mumps, rubella)
☐ Chicken pox
☐ Flu shot
☐ Meningitis
☐ Other: Click here to enter
text.
Is the child current with their vaccination schedule? Choose an item.
Has your child had any adverse reactions to a vaccination? Choose an item.
If yes, explain: Click here to enter text.
Prenatal History
Choose an item.
Was this a planned pregnancy?
Were there any fertility issues? Describe: Click here to enter text.
Was the child conceived using fertility treatments? Choose an item. If yes, explain: Click here to
enter text.
What was the health of the parents at conception?
Mother: Choose an item.
Father: Choose an item.
What was the mother’s health during pregnancy? Choose an item.
What was the mother’s diet during pregnancy? Choose an item.
Did the mother experience any of the following during the pregnancy (check applicable):
☐ Emotional Stress
☐ Nausea
☐ Vomiting ☐ High Blood Pressure ☐ Diabetes
☐ Placenta Previa
☐ Toxemia ☐ Bleeding ☐ Thyroid Problems
☐ Ultrasounds
☐ Physical Trauma
☐ Exposure to cigarette smoke
☐ Other: Click here to enter text.
Describe any particular food cravings during the pregnancy? Click here to enter text.
What was the mother’s age at the child’s birth? Click here to enter text. Father’s age at birth? Click
here to enter text.
Are there any genetic concerns with regards to the parents or the child? Describe. Click here to
enter text.
Did the mother receive any prenatal medical care? Choose an item.
Did the mother work during the pregnancy? Choose an item.
If yes, how long? Click here to
enter text.
Did the mother use any of the following during the pregnancy?
☐ Tobacco ☐ Alcohol ☐ Caffeine ☐ Recreational Drugs: Click here to enter text.
☐ Prescription Medications: Click here to enter text.
☐ Over the counter Medications: Click here to enter text.
☐ Supplements: Click here to enter text.
☐ Other: Click here to enter text.
Birth History
Term Length: ☐ Premature: Click here to enter text.wks ☐ Early: Click here to enter text.wks
☐ Full ☐ Late: Click here to enter text.wks
Birth weight: Click here to enter text. Birth Length Click here to enter text.
APGAR score: 1min Click here to enter text. 5min Click here to enter text.
Delivey by: ☐ Vaginal Birth ☐ Cesarean, why? Click here to enter text.
Check if any of the following interventions apply to the birth:
☐ Forceps ☐ Vacuum extractions ☐ External fetal monitor
☐ Induction of labour ☐ Other: Click here to enter text.
☐ Epidural ☐ Pitocin
Were there any complications during/after delivery? Click here to enter text.
If male, has the child been circumcised? Choose an item.
Did the child experience any of the following at or shortly after birth?
☐ Jaundice ☐ Rashes ☐ Seizures ☐ Birth injuries: Click here to enter text.
☐ Birth defects: Click here to enter text.
☐ Other: Click here to enter text.
Did the child receive any regular medical care during their first year? Choose an item.
By whom? Click here to enter text.
Please indicate any medical problems during baby’s newborn/infancy period: Click here to enter
text.
Nutrition & Diet
Was your child breastfed? Choose an item. If yes, for how long? Click here to enter text.
If formula was introduced, when? Click here to enter text. What type? Click here to enter text.
When were solid foods introduced? Click here to enter text.
Which foods were introduced first? Click here to enter text.
Any reactions? Please describe: Click here to enter text.
Please list any food allergies or intolerances: Click here to enter text.
Does your child have any dietary restrictions (religious, vegetarian/vegan, etc.)? Click here to
enter text.
Does your child have any food aversions? Click here to enter text.
Is your child a “picky” eater? Please explain: Click here to enter text.
Has your child had any unusual feeding/dietary issues or habits? Click here to enter text.
Milk intake now:
☐ Cow milk (☐ Non-fat ☐ 1% ☐ 2% ☐ Whole) ☐ Soy milk ☐ Rice milk
☐ Other: Click here to enter text.
How often does your child:
Drink soda pop? Choose an item.
Have caffeine? Choose an item.
Eat chocolate? Choose an item.
Eat candy? Choose an item.
Eat take-out/fast food? Choose an item.
Please describe a typical day’s diet:
Breakfast
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enter text.
Lunch
Dinner
Snacks
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enter text.
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enter text.
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enter text.
Beverages
(incl. amounts)
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enter text.
Sleep
Does the child sleep through the night? Choose an item.
Hours per night Click here to enter text.
Naps (number & length) Click here to enter text.
Does the child feel sleepy during the day? Choose an item. At what time? Click here to enter text.
Any sleeping problems? Click here to enter text.
Does the child have night terrors/nightmares? Choose an item.
How often? Click here to enter text.
Does the child have any recurring themes in their dreams? Describe: Click here to enter text.
Development
Child’s weight: Click here to enter text. Child’s height: Click here to enter text.
At what age did your child:
Sit alone?Click here to enter text. Crawl? Click here to enter text. Walk alone? Click here
to enter text. Say words? Click here to enter text. Toilet train? Click here to enter text.
First tooth eruption? Click here to enter text.
Lifestyle/Environment
Is the child presently in: ☐ School ☐ Daycare
☐ Homecare ☐ Other: Click here to enter
text.
Which best describes the child’s home: ☐ Rural ☐ Sub-urban
☐ Urban
What are your child’s favourite activities/interests? Click here to enter text.
Is your child exposed to cigarette smoke? Choose an item. If yes, how often? Click here to enter
text.
Do you have pets: ☐ No
☐ Yes, please list: Click here to enter text.
Do you know of any environmental toxins or hazards (chemicals, fumes, dust, etc) your child is
regularly exposed to? Click here to enter text.
How often does your child:
Activity
Watch TV/Videos
Play videogames
Work on computer
Play sports
Exercise
Read (or is read to)
Outdoor activities
Other: Click here to
enter text.
How often?
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item.
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Please describe your child’s temperament: Click here to enter text.
Please describe any fears/anxieties/worries your child has: Click here to enter text.
Please describe your child’s behaviour and performance at school: Click here to enter text.
If over 4 years old, does your child have a “best” friend?
Choose an item.
Are there any concerns about relationships with:
Teachers:
☐ No
☐ Yes, Click here to enter text.
Peers:
☐ No
☐ Yes, Click here to enter text.
Siblings:
☐ No
☐ No
☐ Yes, Click here to enter text.
☐ Yes, Click here to enter text.
Parents:
Other: Click here to enter text.
Is the child known to have or suspected of having any learning disability/difficulty? Describe:
Click here to enter text.
If applicable, how many nights per week does the child have homework? Click here to enter text.
How many hours per night does the child usually spend on homework? Click here to enter text.
How would you describe the emotional climate of the child’s home? Click here to enter text.
Is there any other relevant information you would like to discuss that has not been covered? Click
here to enter text.