Health History Form Birth To 5 Page 2
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3Health History Form
Birth to 5
Birth History
CIRCLE if applies
Additional Information (ex: Date / Details)
Birth Location / Hospital
Type of Delivery / Complications
Vaginal
Cesarean
Gestational Age
Full Term
Birth Complications
None
Apgar Scores
Blood Type
Oxygen at birth
Yes
No
NICU Stay
Yes
No
Synagis prophylaxis given in hospital
Yes
No
Birth weight
Discharge weight
Length
Head circumference
Hep B given birth
Yes
No
Mother's pregnancy health
Normal
Newborn Screening Test
CIRCLE One
Newborn Hearing Test
Normal
Abnormal
Not Performed
Newborn State Screen (PKU)
Normal
Abnormal
Not Performed
Supplemental State Screen
Normal
Abnormal
Not Performed
Other Newborn Screening test
Normal
Abnormal
Not Performed
Patient's
CIRCLE One
Details
Surgical / Hospitalization History
Non-Surgical hospitalizations
None
Yes
Surgical History
None
Yes
Ear Surgery
None
Yes
Nose/Mouth/Throat Surgery
None
Yes
Respiratory Surgery
None
Yes
Cardiovascular Surgery
None
Yes
GI Surgery
None
Yes
GU Surgery
None
Yes
Eye Surgery
None
Yes
Orthopedic Surgery
None
Yes
Plastic Surgery
None
Yes
Other Surgery
None
Yes
Child Social History
CIRCLE all that apply
Parent Information:
Parents together
Father involved
Guardian parents
Lives w/Mother
Mother not involved
Same sex partners
Lives w/Father
Mother involved
Other: _______________________
Father not involved
Mother / Father deceased
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