1800 Howell Mill Rd NW, Ste. 475
Atlanta, Georgia 30318
678-961-2100
www.PediatricEndo.com
Family/Medical History
Who has diabetes in the family?
Who has thyroid disease in the family?
Father’s history: Age
Height
Weight
.
Medical problems:
Onset of Puberty: early average late
Mother’s history: Age
Height
Weight
.
Medical problems:
Age of first menstrual period:
FULL Siblings (does not include half siblings)
1) Name:
Age:
Height:
Weight:
.
Weight:
.
a. Male/female
b. If female, aget at first menstrual period:
c. Medical problems:
2) Name:
Age:
Height:
a. Male/female
b. If female, aget at first menstrual period:
c. Medical problems:
3) Name:
Age:
Height:
Weight:
.
Weight:
.
a. Male/female
b. If female, aget at first menstrual period:
c. Medical problems:
4) Name:
Age:
Height:
a. Male/female
b. If female, aget at first menstrual period:
c. Medical problems:
Maternal Grandfather: Height:
Weight:
Maternal Grandmother: Height:
.
Weight:
.
Mother’s Siblings: Male/Female
Height:
Weight:
.
Mother’s Siblings: Male/Female
Height:
Weight:
.
Mother’s Siblings: Male/Female
Height:
Weight:
.
Mother’s Siblings: Male/Female
Height:
Weight:
.
Paternal Grandfather: Height:
Weight:
.
Paternal Grandmother: Height:
Weight:
.
Father’s Siblings: Male/Female
Height:
Weight:
.
Father’s Siblings: Male/Female
Height:
Weight:
.
Father’s Siblings: Male/Female
Height:
Weight:
.
Father’s Siblings: Male/Female
Height:
Weight:
.
Is anyone taller than 6 feet 7 inches or shorter than 4 feet 11 inches on either Mother or
Father’s side of the family? If yes, on which side (circle one): Mother/Father
Who lives at home with the patient?
Mother’s Occupation:
Father’s Occupation:
Special family circumstances (ie divorce):
Mother’s Perinatal History
Weight gain during pregnancy:
lbs
Bleeding: Yes/No
Infection: Yes/No
Use of drugs during pregnancy: Yes/No
Use of tobacco during pregnancy: Yes/No
Use of alcohol during pregnancy: Yes/No
Hormone use during pregnancy: Yes/No
Labor/Delivery complications: Yes/No
If so, what complications?
Birth History
Gestational age:
weeks
Patient’s birth weight?
lb
oz
Patient’s birth length?
inches
Jaundice (yellow skin) present at birth? Yes/No
Complications after birth? Yes/No
Past Medical History
Infant/toddler feeding problems? Yes/No
Immunizations up to date? Yes/No
Past hospitalizations/surgeries? Yes/No
If yes, what kind of surgery and when?
Trauma (car accidents, broken bones, other serious injury)? Yes/No
If yes, what kind of trauma and when?
Growth/Development Milestones
Teeth erupted? Yes/No (If yes, indicate what age teeth first appeared:
Patient walking? Yes/No (If yes, how old when first started walking?
Language Development (circle one): early average late
Potty trained? Yes/No (If yes, at what age?
)
What grade is your child in school?
What kind of grades does your child receive?
Has attendance been normal, or does your child miss a lot of school?
)
)