Practice Site
Patient Name: _______________________
DOB: ________________
Date: ________________
Allergies: (Include Drug, Reaction, and Age of Onset):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Current Problems:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
History:
Birth History:
Birth Length: _________________
Discharge Weight: _____________
Duration of Labor: _____________
Birth Weight: ______________________
Gestational Age at Birth (weeks): ______
Birth Head Circumference: ___________
Delivery Method: □ Vaginal □ C-Section
If C-Section why? ___________________
APGAR 1m: ___________________
APGAR 5m: ________________________ APGAR 10m: _______________________
Infant Feeding: □ Breast □ Bottle □ Both
Formula Name? ____________________ Newborn Hearing Screening: □Pass □Fail
Other Comments: ____________________________________________________________________________________________
Medical History: (Check Appropriate Box and Comment in Margins)
ADD/ADHD ____________________
YES NO
Anemia _______________________
YES NO
Congenital Heart Disease _________
YES NO
Developmental Delay ____________
YES NO
Eczema _______________________
YES NO
GE Reflux _____________________
YES NO
Murmur ______________________
YES NO
Recurrent Otitis (ear infections) ___
YES NO
Seizures ______________________
YES NO
UTI __________________________
YES NO
Vesicoureteral Reflux ___________
YES NO
Allergic Rhinitis ___________________
Asthma _________________________
Constipation _____________________
Diabetes ________________________
Food Allergies ____________________
Mental Illness ____________________
Prematurity ______________________
Recurrent Strep Throat _____________
Substance Abuse __________________
Vision Problems ___________________
Wheezing ________________________
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Other Medical History: _________________________________________________________________________________________
____________________________________________________________________________________________________________
Surgical History (Check Appropriate Box)
Date
Adenoidectomy (adenoids removal) _______
Appendectomy (appendix removal) _______
Ear Tubes ____________________________
Fundoplication ________________________
Gastronomy Tube Placement ____________
Heart Surgery _________________________
Hernia Repair _________________________
Orthopedic Surgery ____________________
Tonsillectomy _________________________
Urologic Surgery _______________________
VP Shunt _____________________________
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
Surgeon
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Other Surgical History: _________________________________________________________________________________________
____________________________________________________________________________________________________________
Practice Site
Patient Name: _______________________
DOB: ________________
Date: ________________
Parents
Siblings
Aunts/
Uncles
Grandparents
Other
Thyroid Disease
Substance Abuse
Seizures
Migraines
Mental Illness
Kidney Disease
Hypertension
High Cholesterol
Heart Disease
GI Problems
Eye Disease
Diabetes
Cancer
Asthma
Anemia
D
D
D
D
D
D
D
D
D
D
D
D
Allergies
A
A
A
A
A
A
A
A
A
A
A
A
ADD/ADHD
Name
Mother
Father
Sister
Brother
*M Aunt
*M Uncle
*P Aunt
*P Uncle
*MGM
*MGF
*PGM
*PGF
D: Deceased
Relationship
To CHILD
A: Alive
Family History: (Check All Boxes That Apply)
Comments (including other family medical problems): ________________________________________________________________
*M=Maternal, the patient’s mother’s side of the family *P=Paternal, the patient’s father’s side of the family
Additional Family History, including other siblings, may be added below:
Relationship
to Child
Name
A
A
A
A
A
A
A
Home Environment:
Number of People at Home:
Lives with biological parents:
Foster Care:
Primary Care Givers:
Daycare (hours/day):
Time at relatives (hours/day):
Pets:
Smokers in Home:
D
D
D
D
D
D
D
___________
□ Yes □ No
□ Yes □ No
□ Parents
___________
___________
□ Yes □ No
□ Yes □ No
□ Daycare
□ Relatives
□ Other: ___________________________
If Yes, who? ______________________________________________________
Parent’s Status:
Parent’s marital status:
□ Married
□ Divorced
Mother’s Occupation: __________________________________
□ Single
□ Other: ____________________________
Father’s Occupation: _________________________________