DAVZ02 Childrens Medical History Form

New Pediatric Physical Health History Form

Child's Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Age

Name of Parent /Legal Guardian

First NameLast Name

Relationship to Patient

Past Medical History

General health of the patient

ExcellentGoodFairPoor

Does the patient currently see a specialist or has seen one in the past year?

YesNo

Name of Specialist or Practice

Reason & Year

Office Contact or Location

Recent injuries & location

Hospitalizations/ Surgeries

	Year	Reason	Hospital
1.
2.
3.
4.

Is your child under 5 years old?*

YesNo

Birth History (for children under 5 years)

Birth Weight

Length

Length of Gestation (in weeks)

Mother's age at delivery

Delivery type

VaginalC-Section

Any complications during pregnancy or delivery

Is your child under 2 years old?*

YesNo

Feeding History (for children under 2 years)

Currently breastfeeding?

YesNo

Breastfed in the past?

YesNo

Formula name & type (if applicable):

Soft food added when?

Is the patient drinking well water?

YesNo

Is the patient taking Fluoride?

YesNo

Vitamin supplement?

YesNo

Is the patient at risk for Lead exposure?

YesNoUnsure

Feeding concerns or information

Immunization / Health Screening History

Is the patient’s immunization up to date?

YesNo

Last dental exam (if applicable for age):

Last eye exam (if applicable for age):

Had ear infections in the past?

YesNo

If Yes, how many times in the past year?

Had chickenpox in the past?

YesNo

If Yes, what year?

Had tonsillitis in the past?

YesNo

If Yes, how many times in the past year?

Family History

Type a question

	Age	General State of Health
Father
Mother
Sibling #1
Sibling #2
Sibling #3

Who does the patient live with?

Social History

Is the patient presently in Daycare or School?

YesNo

Name of School

Grade

Any scholastic problems or concerns

Does the patient participate in sports?

YesNo

Type of sports

Exercise

Regularly (4x/wk)OccasionallyNone

Type of Exercise

Does the patient regularly wear safety gears (ex. Helmets, mouth guard, arm/kneepads)?

YesNo

Does anyone in the household smoke?

YesNo

Does anyone in the household binge drink?

YesNo

Does anyone in the household use illicit drugs?

YesNo

If a gun or weapons are present at home, is it locked away?

YesNo

Do you follow any special diet at home?

YesNo

If Yes, please describe:

Is the nutritional intake adequate?

YesNo

Medication History / Allergies

Prescription Medications

Over-the-Counter Medications / Supplements

Medication Allergies & Reactions:

Preferred Pharmacy & Location