Health History Form Birth To 5
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1
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3Health History Form
Birth to 5
Date: _______________________
Name: _______________________________
DOB: _______________________
Pharmacy: ____________________________________________________________________________________
Please CIRCLE One
Primary Language in home:
English
Spanish
Other: _____________________________
Ethnicity:
Not Hispanic or Latino
Hispanic or Latino
Race:
White
Asian
Native Hawaiian / Pacific Islander
Black / African American
2 or more races
Current Medications:
Allergies:
Patient's Past Medical History
CIRCLE One
Additional Information (ex: Test / Date / Details)
Prior Testing/Development Test
None
Yes
Test:
Allergies
No
Yes
History of Chicken Pox
No
Yes
Date:
Cancer
No
Yes
Blood/Lymph Disorder
No
Yes
Diabetes
No
Yes
Endocrine/Metabolic Disorder
No
Yes
Nose, Mouth, Throat Disorder
No
Yes
Cardiovascular Disorder
No
Yes
GI Disorder
No
Yes
GU/Kidney Disease
No
Yes
Musculoskeletal Disorder
No
Yes
Neurologic Disorder
No
Yes
Psychiatric/Learning Disorder
No
Yes
Skin Disease
No
Yes
History of Injury/Trauma
No
Yes
Details:
Other Medical History
No
Yes
Family Health History
CIRCLE One
Please List Family Member & details below
Bleeding disorder
No
Yes
Cancer
No
Yes
Diabetes
No
Yes
Cardiovascular disorder
No
Yes
Congential heart disease
No
Yes
Eye disorder
No
Yes
Ear disorder
No
Yes
Respiratory disorder
No
Yes
GI disorder
No
Yes
Musculoskeletal disorders
No
Yes
Neurologic disorder
No
Yes
Psychiatric disorder
No
Yes
SIDS
No
Yes
Skin disease
No
Yes
Other Medical History
No
Yes
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