KACHINA FAMILY PRACTICE CHILD MEDICAL HISTORY (10 AND UNDER)
First Name:
SEX:
Last Name:
M
RACE:
F
DOB:
White
Pharmacy Name:
Age
Hispanic
Black
email :
Asian
Native American or Alaskan
Cross-Streets:
Pacific Islander
Pharmacy #:
Do you have any specific concerns about your childs health? please specify
CURRENT MEDICATIONS (INCLUDING OTC )
Dose:
1.
Times / day
MED. ALLERGY or
VACCINE REACTIONS?
2.
Dose:
Times /day
Name of the Med. or Vaccine:
PREGNANCY AND BIRTH HISTORY
Is this child your's by:
3.
Dose:
Times /day
What reaction occurred?:
birth
stepchild
adoption
Other
Please indicate any medical problems during pregnancy if applicable
Type of Delivery
Complications?
Birth Weight
Was your child premature?
If so, how early?
Please indicate any medical problems during the baby's newborn period if applicable
NUTRITION
AND
FEEDING
SLEEP
Has your child ever had any unusual dietary problems? If so, please specify
Type of Milk or Formula
Naps, number and length
Hours per night
DEVELOPMENT
At what age did your child Sit Alone?
EXPOSURES/HABITS
PREVENTIVE CARE
Any sleeping problems?
Walk Alone?
TV- hours per day
Video games-hours per day
Exercise
Diet
Has your child been seen by a dentist?
Please indicate if your child has had
any of the following diseases
Chicken Pox
Toilet train?
Computer-hours per day
Do any household members smoke?
Date of last visit?
Measles
Mumps
When was your childs last physical?
Rubella
Meningitis
Tuberculosis
PAST MEDICAL HISTORY
Please describe any major medical problems and their approximate dates.
Please list any surgeries your child has had and the approximate dates.
Has your child ever been hospitalized? if yes - please specify when and why?
FAMILY MEDICAL HISTORY
Mother------------>
Alive
Deceased,Age:
Alzheimers
Arthritis
Asthma
Cancer,Type:
Heart Disease
High Cholesterol
Depression
continued
Alcoholism
Diabetes, Type:
High Blood Pressure
Migraine
Obesity
Osteoporosis
Kidney Disease
Stroke
Thyroid Disorder
Father------------>
Alive
Deceased,Age:
Alzheimers
Arthritis
Asthma
Cancer,Type:
Heart Disease
High Cholesterol
Depression
SOCIAL HISTORY What grade is your child in?
Who lives at home with your child?
How did you hear about Kachina Family Practice?
continued
Alcoholism
Diabetes, Type:
High Blood Pressure
Migraine
Obesity
Osteoporosis
Kidney Disease
Stroke
Thyroid Disorder
What grades does your child get?
Are there problems at home?
Brothers
Sisters
Alive
Deceased,Age:
Alzheimers
Arthritis
Asthma
Cancer,Type:
Heart Disease
High Cholesterol
Depression
Alcoholism
Diabetes, Type:
High Blood Pressure
Migraine
Obesity
Osteoporosis
Kidney Disease
Stroke
Thyroid Disorder
Are there problems at school?
if so, please specify