Pediatric Medical History Form printable pdf download

Pediatric Medical History Form

Name: _____________________________ DOB: ________________ Age: _________ Date: _________

Grade in school ______________________

Reason for Today’s Visit: ______________________________________________________________

Past Medical History: (list all surgeries and hospitalizations)

1. ____________________________________________________________________________________

2. ____________________________________________________________________________________

3. ____________________________________________________________________________________

Problems for which you have seen a physician or been treated for: (please circle yes or no)

Cancer:

Yes (specify_____________________________________)

Respiratory:

Yes (specify_____________________________________)

Heart:

Yes (specify_____________________________________)

Thyroid:

Yes (specify_____________________________________)

Other: ________________________________________________________________________________

Drug Allergies and Reactions:

1. ________________________________________ 3. _________________________________________

2. ________________________________________ 4. _________________________________________

Immunizations:

Up to Date?

Yes

Family History:

Age

Height

Weight

Age @ Puberty

Health Problems

Mother

(menses)

Father

(shaving)

Brother

Sister

Others

Please note any family history of:

Tallness (Women > 5’10” and Men > 6’) ____________________________________________________

Shortness (Women < 5’ and Men < 5’3”) ____________________________________________________

Calcium Problems (kidney stones) __________________________________________________________

Early Deaths ___________________________________________________________________________

Pediatric Medical History Form