Pediatric Medical History Form Page 2
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2(Pediatric medical history continued….)
*Patient Name:________________________________________________
Date of Birth: _________
Social:
Live w/Others
No
Yes
________________________________________________________
Exercise:
No
Yes
Hours per week: __________________
Smoke:
No
Yes
Amount/Day: ___________________
Alcohol:
No
Yes
Ounces/Day:
___________________
Sexually Active: No
Yes
Smoke Exposure No
Yes
Medications:
List any medications you are currently taking with dosage (include over the counter & vitamins or
supplements:
1. ________________________________________ 4. _________________________________________
2. ________________________________________ 5. _________________________________________
3. ________________________________________ 6. _________________________________________
Birth History:
Maternal health during pregnancy (specify):
Were there hospital stays? ________________________________________________________
Were there illnesses? ____________________________________________________________
Drugs/substances used? __________________________________________________________
Medications prescribed? __________________________________________________________
Ultrasounds out of the ordinary? ___________________________________________________
Fetal movement normal? _________________________________________________________
Pre-Natal Care? Yes
No
Prenatal vitmamins?
Yes
No
Neonatal:
Type of Birth (circle):
vaginal
C-Section
Birth weight: ____________
Birth length: ____________
Neonatal problems (circle):
Resuscitation
Jaundice
Floppy
Home with Mom
Extended hospital stay
What did you last eat for:
Breakfast:
Lunch:
Dinner:
Provider initials ___________Reviewed completed forms with patient.
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Parent category: Medical