Patient Medical History Questionnaire Form printable pdf download

Patient Medical History Questionnaire

Today’s Date:_________

Patient’s Name:______________________________________Date of Birth:__________________Age Today:________________

Reason for Today’s Visit:_____________________________________________________________________________________

Do you have a record of this child’s immunizations with you today? No/Yes

PAGE 1

Please indicate answers by filling in the blanks or by circling ‘No’ or ‘Yes’

If adults in the household work outside the home, what

childcare arrangements are made for this

FAMILY HISTORY

child?________________________________________

Are the child’s parents both in good health? No/Yes

Circle any disease that the child’s siblings, parents,

_____________________________________________

grandparents, aunts, uncles or 1

cousins have: AIDS, alcohol

Are there any cultural concerns we need to be made aware

problems, allergies, asthma, blood disorders, cancer, diabetes,

of?___________________________________

drug problems, epilepsy, heart trouble, high blood pressure,

high cholesterol, inherited illness, kidney disease, liver

Who lives in the home with your child?

disease, lung disease, lupus, mental illness, multiple sclerosis,

muscular dystrophy, SIDS, tuberculosis, venereal disease,

Name

Relation

others.

Use this space to note which relative has which disease:

Sibling-Name/Birthdate / Sex/General Health Problem(s)

__________/________/____/______________________

Have any siblings died? No/Yes

If yes, cause of death____________________________

PREGNANCY AND BIRTH

PAST MEDICAL HISTORY

Mother’s age at birth of child?___________________

Where has your child gone for check-ups until now?

Did mother have any illness during pregnancy?

_________________________________________

____________________________________

Date of last check-up:_______________________

Did she take any medications other than vitamins and iron?

Date of last dental check-up:__________________

No/Yes

Has your child had any allergic reactions to any medications,

What hospital/birth center?______________

foods, or insect bites?

No/Yes

Was the baby on time?

No/Yes

Which ones________________________________

Was the birth by C-section or vaginal?______

Has your child had a bad reaction to any immunizations?

Obstetrician/Midwife name______________

No/Yes

Which ones________________________

Pediatrician who saw the baby in the hospital?

Any hospitalizations/surgeries other than for birth?

No/Yes

____________________________________

For what?___________________________________

What was the birth weight _______Length________

____________________________________________

Did the baby have any trouble starting to breathe?

No/Yes

____________________________________________

Did the baby have any problems while in the hospital? No/Yes

Any chronic illnesses?

No/Yes

(Jaundice, infections, other?)__________________________

If so, please list_______________________________

Did the baby receive Hepatitis B vaccine in the nursery? No/Yes

Any serious injuries, broken bones, stitches?

No/Yes

Please note any other important facts:

What kind?___________________________________

______________________________________________

Are any medications taken regularly?

No/Yes

______________________________________________

Which ones?__________________________________

Has your child has/had any of the following: (circle)

Rubella(German Measles), Pertussis (Whooping Cough),

Strep Throat, Chicken Pox, Diptheria, Scarlet Fever,

Tonsillitis, Heart Murmur, Diabetes?

Patient Medical History Questionnaire Form

Related Articles

Related forms

Related Categories