Pediatric Health History: Ages 0-1
Patient Name:
Patient Gender: Male / Female
Patient Date of Birth:
Patient’s Age:
Patient Social Security Number:
Today’s Date:
Pregnancy and Birth
Where was the child born? Please list the state and hospital.
Please indicate if mother had any of the following problems during pregnancy:
Bleeding, Gestational Diabetes, Hepatitis B, Herpes, High Blood Pressure, Illnesses/Infections,
Preterm Labor, Spotting, Threatened Miscarriage, Toxemia, Other
If illnesses or infections please specify:
If other, please specify:
Were any medications taken during pregnancy? Please choose all that apply.
Prenatal Vitamins, Other
If other, please specify:
What was the length of pregnancy (in weeks)?
What was the length of labor (in hours)?
What was the method of delivery?
Vaginal , C-Section
Please list the child’s Apgar scores, if known.
Did child breathe immediately after birth?
Birth Weight:
Birth Length:
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Pediatric Health History: Ages 0-1
Patient Name:
Did mother or child experience any of the following complications of delivery? Please check all that apply:
Prolonged Labor, Needed Oxygen, Jaundice, Phototherapy, Needed Resuscitation, ICU Stay, Other
If ICU Stay, why?
If other, please specify:
Medical History
Please list hospitalizations, operations or accidents (with dates):
Has the child experienced any of the following medical illnesses/problems/infections? Please choose all that apply:
Allergies, Asthma, Chicken Pox, Diabetes, Developmental Delays, Ear Infections, Eczema, Head Injuries,
Meningitis, RSV, Seizures, Tuberculosis, Urinary Tract Infections, Whooping Cough (Pertussis), Other
If other, please specify:
At what age did the child reach the following milestones? If the child has not reached the milestone, please mark “N/A”
Smiles
Giggles
Rolls Over
Sits
Crawls
Pulls to Stand
Imitates Speech Sounds
Nutrition and Sleep
Is/was the child breast fed?
Until what age?
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Pediatric Health History: Ages 0-1
Patient Name:
At what age did the child start eating solids (if applicable)?
Has the child had feeding problems?
If yes, please specify:
How many hours does the child sleep per night?
Does the child have any sleep problems?
Medications
Please list all current medications:
Medication Name
Dosage
Frequency
Status (Active)?
Immunizations
Are the child’s immunizations up to date? (Please bring immunization records to visit)
Family History
For each of the following blood relatives, please describe the health status, severe illness(es), death and age at death as they
apply.
Father
Mother
Sister(s)
Brother(s)
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Pediatric Health History: Ages 0-1
Patient Name:
Status of child’s parents: (choose which applies)
Married, Never Married, Divorced, Single Parent
Who lives at home with the child? Please list all people and their relationships to the child.
Is child care…?
Provided at home, Provided away from home
Please specify if blood relatives have had any of the following. Choose all that apply:
Heart disease, High Blood Pressure, Kidney Disease, Allergies/Asthma, Cancer, Deafness, Diabetes,
Mental/Emotional Problems, Sickle Cell, Seizures, Other hereditary condition, Tuberculosis, HIV/Aids or
Immune Problems
If other, please specify:
Exposure to Smoke
Please specify if any of the following apply:
No smokers in household, Family members smoke indoors, Family members smoke outdoors only,
Caregiver smokes indoors, Caregiver smokes outdoors only, Other exposure to second hand smoke
If smokers, please specify relationship above
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