TODAY’S DATE:________________________
PEDIATRIC HISTORY FORM
Parents – Please answer the following questions about your child.
PATIENT NAME: __________________________________ DATE OF BIRTH: _________________
MEDICATION – List all current medications and dosages ALLERGIES/REACTION TO MEDICATION
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_______________Latex Allergy:  Yes
 No
HOSPITAL ADMISSIONS
Year
Illness or Operation/Physician
________
_____________________________
Year
_________
Illness or Operation/Physician
____________________________
________
_____________________________
_________
____________________________
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_____________________________
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PATIENT SYMPTOMS- Please check all that apply
 Ear infection-frequent
 Diarrhea/Constipation
 Vision Problems
 Feeding Problems
 Eye Problems
 Jaundice/Hepatitis
 Nose bleeds-recurrent
 Hernia
 Sinus trouble
 Problems with Urination
 Sore throats-frequent
 Weight Loss-recent
 Hayfever/Allergies
 Anemia
 Pneumonia/Pleurisy
 Convulsions/Seizures
 Bronchitis/Chronic cough
 Headaches
 Asthma/Wheezing
 Bone Fracture/Joint injury
 Heart Murmur
 Rashes/Hives
 Loss of appetite-recent
 Psoriasis/Eczema
 Abdominal Pain-chronic
 Mood Swings/Depression
 Phobias
 Measles/Mumps/Chicken pox
 TB/Polio/Rheumatic fever
 Bedwetting
 Nightmares/Sleep problems
 Irritable/Bad temper
 Discipline problems
 Speech problems
 Thumb Sucking
 Anorexia/Bulimia
 Any developmental delays (eg late walking)
 School problems
Last dental exam: __________
Last eye exam: ____________
BIRTH HISTORY- Please check all that apply
Weight at Birth: ____________
Full Term:
Was the delivery:
Any Pregnancy Complications?
Any Problems with the Delivery?
Any Problems in the Nursery?
While Pregnant did Mother use:
Birth Length: ____________
Birth Location: _____________
 Yes  No If premature, how early? ____________________
 Vaginal  C-Section  Forceps
 Yes  No If yes, explain: ____________________________
 Yes  No If yes, explain: ____________________________
 Yes  No
If yes, explain: ____________________________
Was child breastfed?
 Yes
How long? __________
Alcohol:
 Yes  No
 No
Drugs:
 Yes  No
Cigarettes:
 Yes  No
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PATIENT NAME: ______________________________________________________________
SOCIAL HISTORY- Please circle the appropriate answer
 Yes  No
Anyone smoke in the home?
 Yes  No
Do parents/caregivers consume Alcohol/Drugs?
 Yes  No
Do parents/caregivers have any concerns about Smoking/Alcohol/Drug use by child or his/her peers?
 Yes  No
Do parents (or adolescent) have concerns about Sex/Birth Control for adolescent?
 Yes  No
Are there any Guns in the house?
Are they locked up/out of reach?  Yes  No
 Yes  No
Are all Medicines/Chemicals out of reach?
 Yes  No
Is Syrup of Ipecac available in home?
 Yes  No
Do parents know CPR?
 Yes  No
Does child use seatbelts/car seat every car ride?
Do parents?
 Yes
 No
 Yes  No
Do you have smoke detectors/fire escape plan?
 Yes  No
Does child wear helmet when biking/roller blading? Do parents?
 Yes
 No
FEMALES ONLY-Skip this section if patient is not menstruating.
Ever had Pap Smear:  Yes  No Date of last pap: ____________
Last Menstrual Period: _______________ Flow is:  Heavy  Moderate  Light Flow is:  Regular
Age at first menses______years old
How often are periods? Every ________days.
How long are periods? __________days
 Irregular
FAMILY HISTORY-Has any blood relatives suffered from the following? If yes, list who.
 Heart Murmur _______________
 High Blood Pressure
_______________
 Stroke
_______________
 Heart Disease
_______________
 Migraine
_______________
 Skin Problems
_______________
 Diabetes
_______________
 Psoriasis/Eczema
_______________
 Cancer
_______________
 Liver Disease/Hepatitis _______________
 Arthritis
_______________
 Lung Disease
_______________
 Asthma
_______________
 Tuberculosis
_______________
 Sickle Cell Dz. _______________
 Alcohol/Drug Abuse
_______________
 Anemia
_______________
 Mental Illness
_______________
 Kidney Disease _______________
 Depression
_______________
 Allergies
_______________
 Thyroid Problems
_______________
 Glaucoma
_______________
 HIV/AIDS
_______________
MOTHER
FATHER
BROTHERS &
SISTERS
NAME
____________________
____________________
____________________
____________________
____________________
____________________
____________________
AGE
_____
_____
_____
_____
_____
_____
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GENERAL HEALTH
 Good  Poor  Deceased __________________
 Good  Poor  Deceased __________________
 Good  Poor  Deceased __________________
 Good  Poor  Deceased __________________
 Good  Poor  Deceased __________________
 Good  Poor  Deceased __________________
 Good  Poor  Deceased __________________
_________________________________________________________________________________________________
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Signature of person completing form: ________________________/Relationship to child: __________Date: __________
HISTORY REVIEWED BY: _______________________________________________
Signature of Physician/Physician Assistant/ M.A
___/____/____
Date