Best Kids Care
4200 S. Lake Forest Dr. Suite #100, McKinney, Texas 75070
Date:____________________
Pediatric Health History
Your child's health is of the utmost importance to us. Please fill out this form as completely and accurately as you can. If you are unsure how to
answer a certain item, just circle the item and we will be happy to discuss it with you. All information is treated confidentially.
Child’s Name:____________________________________ Date of Birth:____________________Age:____________ M___ F___
Child’s School:_____________________________________________________ Grade:___________________________________
Previous Physician:_________________________________ Phone __________________City/State:______________________
DRUG ALLERGIES
Substance
Reaction
MEDICATIONS
Medication Name
Dosage
MEDICAL HISTORY
Please check if the child has any of the following:
Anemia
CARDOVASCULAR
Asthma
Bronchitis
Chicken Pox
Murmurs
Chest Pain
Irregular Heart Beat
Hepatitis
Measles
EYES
Crossed or
Wandering
Rubella
Eye Irritation
Mumps
Vision problems
Rheumatic Fever HEARING/SPEECH
Pneumonia
Difficulty Hearing
Whooping
Earaches
Cough
Ear Infections
RSV
DENTAL
Speech Problems
Bleeding Gums
Grinding Teeth
Sensitivity
Thumb Sucking
Other:
Last Dental
Check Up:
Brush, how
often?
Floss, how
often?
HOSPITALIZATIONS
REASON
GASTRONINTESTTNAL
Poor Appetite
Bloody/Dark Stool
Constipation
Diarrhea
Excessive Hunger
Excessive Thirst
Nausea
Rectal Bleeding
Stomachaches
Vomiting
MUSCLE/JOINT/BONE
Broken Bones
Sprains
Coordination
Problems
Posture Problems
Pain, weakness or
swelling
GENERAL
Chills
Depression
Dizziness
Fainting
Worms
GENTTO-UR1NARY
NOSE/THROAT/CHEST
Difficulty Breathing
Difficulty Swallowing
Frequent Colds
Hoarseness
Mouth-Breathing
Nosebleeds
Persistent Cough
Sinus Problems
Sore Throat
Strep Throat
Forgetfulness
Headaches
Tonsil Infections
Wheezing
Bedwetting
Blood in Urine
Diaper Rash, Persistent
Discharge
(vagina/penis)
Frequent Urination
Loss of Sleep
Mood Swings
Nervousness
Numbness
SKIN
Bruise Easily
Change in Moles
Hives
Sweating
Rash
Painful Urination
Tiredness
Scars.
Unusual Urine Odor
Weight Loss/Gain
Sores mat won't heal
INJURIES
DATE
HOSPITAL, CITY, STATE
SERIOUS
INJUR1ES/ILLINESS
DATE
OUTCOME