Confidential Medical History Form For Children
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1Confidential Medical History Form for Children
Please bring this completed form to your child's office appointment
Name: _______________________________ DOB: _____________ Today's Date:____________
Birth History for Patient:
Was the pregnancy full term? Y or N
Were there complications with the pregnancy or delivery? Y or N
Did you go home in 24 - 48 hours? Y or N
If not why? __________________________________________
How much did your child weigh at birth?
_______________________
Past Medical History: Has the child had any of the following Conditions?
□ Abdominal problems?
□ Frequent Temper Tantrums?
□ Pneumonia?
□ Any serious injury?
□ Hay fever/Sinus Problems?
□ School Problems?
□ Asthma?
□ Hearing Problems?
□ Seasonal Allergies?
□ Behavior Problems?
□ Heart Problems?
□ Seizures?
□ Broken Bones?
□ Joint/Bone Problems?
□ Skills are behind other kids?
□ Chronic Cough?
□ Kidney or Bladder infections?
□ Underweight
□ Constipation?
□ Many ear infections?
□ Vision Problem?
□ Over Weight?
□ Other? __________________
Any Allergies to Medications?______________________________________________________
Any Medications/Supplements taken frequently? _______________________________________
Social History:
Child has how many sisters?
Brothers?
____________________
________________________
Grade in school/Preschool
_______________________________________________________
Usual Grades received? _________________ (A,B,C’s, Etc.)
Is your child in daycare/after school care?
__________________________________________
Who lives in your home?
_________________________________________________________
Exposures:
□ Is there a smoker in the home/at babysitter’s?
□ Do you always use seatbelt or car seat in your vehicle?
Family History: Has any blood relative of your child had...
□ Alcoholism?
□ Depression?
□ Lung Disease?
□ Allergies?
□ Diabetes?
□ Mental Illness?
□ Asthma?
□ Drug Addiction?
□ Seizures?
□ Bleeding Disorder?
□ Heart Problems?
□ Strokes?
□ Blood Clots?
□ Heart Vessel Surgery?
□ Tuberculosis (TB)?
□ Cancer?
□ High Blood Pressure?
□ Other conditions?
□ Deafness?
□ High Cholesterol?
Parents Signature: ________________________________________________________________
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