PEDIATRIC HISTORY FORM
_______________________________________________________
Childs Name
Age
Today’s date
_________________________
Birthdate
BIRTH HISTORY: BIRTHPLACE________________________________
WAS PREGNANCY NORMAL?_______________________________
WAS DELIVERY NORMAL?__________________________________
WAS BABY FULL-TERM? ___________________________________
BIRTH WEIGHT:____________ LENGTH_______________________
ANY NURSERY PROBLEMS? ________________________________
GROWTH & DEVELOPMENT
AGES WHEN FIRST:
SAT___________________
CRAWLED_____________________
ROLLED________________
WALKED______________________
FIRST TEETH____________
TOILET TRAINED________________
SCHOOL HISTORY:
YEAR IN SCHOOL_______ NURSERY________________________
GRADES AVERAGED______________________________________
SCHOOL NAME: _________________________________________
SCHOOL PROBLEMS:______________________________________
ATTENDS SPECIAL SCHOOL OR CLASSES:______________________
_______________________________________________________
DISCIPLINE OR BEHAVIOR PROBLEMS:_______________________
_______________________________________________________
EVER SEEN BY PSYCHOLOGIST, SPEECH THERAPIST, OR SPECIAL
TEACHERS: _____________________________________________
___________________________________________ ___________
PAST MEDICAL HISTORY:
SLEEPING? ______________ BEDWETTING? ________________
WT/HT?________________ NAIL BITING?__________________
NIGHTMARES? __________________________________________
DIET:___________________________________________________
NURSE OR BOTTLE FED?___________________________________
ANY COLIC PROBLEMS?____________________________________
USE SPECIAL DIETS?_______________________________________
TAKING VITAMINS?_______________________________________
TAKING FLUORIDE?_______________________________________
CONTAGIOUS DISEASES (WHAT AGE?)
MEASLES:_______________ MUMPS______________________
RUBELLA (GERMAN MEASLES) _____________________________
CHICKENPOX_____________ SCARLET FEVER: _______________
ANY OTHER?____________________________________________
IMMUNIZATIONS (SHOTS): PLEASE GIVE AGE OR DATES
DPT SERIES_________________ BOOSTERS: __________________
POLIO SERIES_______________ BOOSTERS: _________________
SMALLPOX_________________ BOOSTERS: _________________
MEASLES__________________ MUMPS ____________________
RUBELLA (GERMAIN MEASLES) _____________________________
TB (TINE) TEST _____________ HIB ________________________
OTHERS?_______________________________________________
MEDICATIONS:DOES YOUR CHILD TAKE ANY NOW?
IF SO, PLEASE LIST: WHEN, WHERE, WHY?
______________________________________________________
______________________________________________________
______________________________________________________
SURGERY: WHEN, WHERE, WHY?
______________________________________________________
______________________________________________________
______________________________________________________
SERIOUS INJURIES: WHEN, WHERE?
______________________________________________________
______________________________________________________
______________________________________________________
ALLERGIC REACTIONS: DRUGS, ASTHMA, HIVES, ECZEMA, HAYFEVER?
______________________________________________________
______________________________________________________
______________________________________________________
FAMILY HISTORY:
FATHER LIVING?_________AGE NOW? _________ HEALTH_______
MOTHER LIVING? _______ AGE NOW? _________ HEALTH_______
BROTHERS/SISTERS________ HOW MANY?_________________
AGES ________ ________ ________ _______ _____ ________
HEALTH_______________________________________________
ANY FAMILY HISTORY OF:
DIABETES: ______________ ALLERGIES:__________________
CONVULSIONS:__________ HEART DISEASE:______________
CANCER:________________ OTHER:_____________________
_____________________________________________________
HOW LONG HAS YOUR FAMILY LIVED IN THIS AREA? ___________
WHERE DID YOU LIVE BEFORE COMING HERE?_________________
_______________________________________________________
GENERAL SURVEY: HAS YOUR CHILD HAD ANY UNUSUAL
PROBLEMS WITH THE FOLLOWING:
HEAD: _________________________________________________
EYES: __________________________________________________
EARS/NOSE/THROAT: ____________________________________
CHEST/HEART/LUNGS: ___________________________________
STOMACH: _____________________________________________
KIDNEYS: ______________________________________________
BLADDER: _____________________________________________
BONES, MUSCLES, JOINTS: ________________________________
SKIN: __________________________________________________
BLOOD: ________________________________________________
WHEN WAS YOUR CHILD’S LAST BLOOD TEST? _________________
WHEN WAS YOUR CHILDED LAST URINE TEST: _________________
ANY SPECIAL COMMENTS ABOUT YOUR CHILD? _________________
________________________________________________________
YOUR CHILD’S LAST DOCTOR WAS: ___________________________
ADDRESS: _______________________________________________