• New Pediatric Physical Health History Form

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Past Medical History

  • General health of the patient
  • Does the patient currently see a specialist or has seen one in the past year?
  • Hospitalizations/ Surgeries
    Rows
  • Is your child under 5 years old?*

  • Birth History (for children under 5 years)

  • Delivery type
  • Is your child under 2 years old?*

  • Feeding History (for children under 2 years)

  • Currently breastfeeding?
  • Breastfed in the past?
  • Is the patient drinking well water?
  • Is the patient taking Fluoride?
  • Vitamin supplement?
  • Is the patient at risk for Lead exposure?

  • Immunization / Health Screening History

  • Is the patient’s immunization up to date?
  • Had ear infections in the past?
  • Had chickenpox in the past?
  • Had tonsillitis in the past?

  • Family History

  • Type a question
    Rows

  • Social History

  • Is the patient presently in Daycare or School?
  • Does the patient participate in sports?
  • Exercise
  • Does the patient regularly wear safety gears (ex. Helmets, mouth guard, arm/kneepads)?
  • Does anyone in the household smoke?
  • Does anyone in the household binge drink?
  • Does anyone in the household use illicit drugs?
  • If a gun or weapons are present at home, is it locked away?
  • Do you follow any special diet at home?
  • Is the nutritional intake adequate?

  • Medication History / Allergies

  • Should be Empty: