Kidder County Community Health Center Pediatric Health Questionnaire 2-18 years.
Patient Name:_______________________________________________Date of Birth:_______________
Do you have any allergies? If yes, please list: ________________________________________________
Drug store preference: __________________________________________________________________
Does this child take any medications, vitamins or supplements daily? If yes, please list below:
Medication
Dose
Frequency
Pediatrician/Family Doctor:______________________________________________________________
Date and Purpose of last doctor visit:______________________________________________________
Date of last Well Child Visit:______________________________________________________________
Immunization Dates: HEP B_________ OPV_________ MMR__________
DTP___________ HIB__________ VAR___________
Date of Childhood Disease: Measles___________ Chicken Pox___________
Whooping Cough__________Mumps_________
Other__________________________________
Has this child been treated for any emergency? Please circle: Yes No
Describe:_____________________________________________________________________________
_____________________________________________________________________________________
Has this child had any surgeries? Please Circle: Yes No
Describe:_____________________________________________________________________________
_____________________________________________________________________________________
Medical History: Please circle
Chicken Pox
Asthma
Hepatitis
Eczema
Heart Murmur
Irregular Pulse
PE Tubes (ear tubes)
Diabetes
Fainting Spell
Psychiatric Problems
Anemia
Ulcers
Hyperactivity
Cancer
Sickle Cell Anemia
Blood transfusion
Appendix removed
Bed wetting
Constipation
Diarrhea
Muscle jerking
Chronic ear aches
Tuberculosis
Walking Problem
Please list any other pertinent medical history this child may have:
Pneumonia
Serious allergic reactions
Cleft palate
High blood pressure
Downs syndrome
Asperger’s Syndrome
Rheumatic Fever
Tonsils removed
Paralysis
Hearing trouble
Ruptures/Hernias
Broken Bones
Family History: Please circle any family history listed below.
Asthma
Rheumatic Fever
Pneumonia
Stroke
Chronic Lung Disease
High Blood Pressure
Tuberculosis
Diabetes
Congestive Heart Failure
Atrial Fibrillation
High Cholesterol
Heart Murmur
Hypothyroidism
Hyperthyroidism
Kidney Infections
Kidney Stones
Chrohn’s Disease
Ulcerative Colitis
Hepatitis
Liver Disease/Problems
Psychiatric Illnesses
Anxiety
Bleeding Disorders
Seizures
Migraines
Tension headaches
Osteoporosis
Chronic neck and back pain
Macular Degeneration
Glaucoma
Leukemia
Juvenile Arthritis
Acid Reflux
Gastro esophageal Reflux Disease
Hiatal Hernia
Gall Bladder Disease
Irritable Bowel Syndrome
Heart Attack
Cancer: Type:________________
Ulcers: Location:______________
Diverticulitis
Depression
Anemia
Epilepsy
Arthritis: Location:____________
Carpal Tunnel
Osteopenia
Sickle Cell Anemia
Social History:
Who is the primary caregiver for this child?_________________________________________________
Does this child attend day care? If yes, where?_______________________________________________
Is this child exposed to second hand smoke?_________________________________________________
Number of children in the home:__________________________________________________________
Has this child ever been exposed to lead?___________________________________________________
What does this child diet consist of?________________________________________________________
Does this child ride in a car seat?__________________________________________________________
Is there anything else we should know about this
child?________________________________________________________________________________
_____________________________________________________________________________________
I certify that the information on this form is true to the best of my knowledge.
Print childs/patients name:______________________________________________________
Signature of parent or legal guardian:______________________________________________