DAVZ02 Newborn 1-7 days old Medical History Form

Newborn Physical Health History Form (Birth- 1st Week)

Child's Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Name of Parent/Legal Guardian

First NameLast Name

Relationship to Patient

Birth History

Birth Weight

Length

Length of Gestation (weeks)

Mother's age at delivery

Delivery Location

HomeHospitalBirthing Center

Delivery Type

VaginalC-Section

Any instruments used during delivery?

YesNo

Any complications during pregnancy?

Any complications during delivery?

Current weight (if known)

Did the newborn experience weight loss at the time of discharge?

YesNoNot sure

Feeding / Intake History

Is the newborn currently breastfed? (Select Yes if the newborn is bottle-fed with breastmilk.)

YesNo

Is the newborn currently on formula?

YesNo

Type & Brand of Formula

Type of water used to mix formula

Feeding freequency

Immunization / Health Screening History

Did the newborn pass the hearing test?

YesNoNot sure

Is the newborn's immunizations up to date?

YesNoNot sure

Is the newborn circumcised (for male newborns)?

YesNo

Hospitalizations / Surgeries / Procedures

	Year	Reason	Hospital
1.
2.
3.

Family History

Type a question

	Age	General State of Health
Father
Mother
Sibling #1
Sibling #2
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather

Who does the newborn live with?

Social History / Medication History / Allergies

Does anyone in the household smoke?

YesNo

Does anyone in the household binge drink?

YesNo

Does anyone in the household use illicit drugs?

YesNo

Do you feel comfortable using a car seat?

YesNo

Prescription Medications

Over-the-Counter Medications

Medication Allergies & Reactions

Preferred Pharmacy & Location