Primary Health Solutions-Pediatric History Form Birth To 12 Years Of Age April 2010
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1
2PRIMARY HEALTH SOLUTIONS
PEDIATRIC HISTORY FORM Birth to 12 years of age
IF YOU HAVE DIFFICULTY FILLING THIS FORM OUT OR
HAVE QUESTIONS ABOUT IT, PLEASE TELL THE NURSE.
Child’s Name: ___________________________ Birthdate: Month___________Day____ Year__________
Today’s Date _____________________ How did you learn about us?_______________________________
Name of person filling out form: _______________________________Relationship to child: ____________
Family History:
Does anyone in the mother's or the father's family have any of the following problems?
Please check YES or NO
YES
NO
WHO?
YES
NO
WHO?
Alcohol or drug problem
Asthma
Diabetes
Heart attack before age 50
High blood pressure
High cholesterol
Lead poisoning
Seizure or epilepsy
Sickle Cell problems
Mental illness
Is there any other serious physical problem, mental problem or disease in the child’s family?
Family Health:
Immediate Family
Age Living with
Health
Name
(Living, Sick, Deceased)
child
Yes No
Mother of Child
Father of Child
Brothers & Sisters
Birth history of child:
___________________________________________________________________________________________________
How many times did the mother see the doctor for prenatal care?
1
2
3
4
5+
Were there any problems with the pregnancy, delivery, or labor?
Did the child’s mother smoke during pregnancy?
Did the child’s mother drink alcohol during pregnancy?
Did the child’s mother take drugs during pregnancy?
Did the child’s mother have any infections that needed treatment?
Was the child’s mother on medications during pregnancy?
What hospital was the child born at?
How many days in the hospital 1 2 3 4+
What was the child’s weight at birth?
Was or is the child breast fed or bottle fed?
Page 1
4/2010
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