Pediatric Health History Form

Transcription

1 Pediatric Health Histry Frm Child s Name Date f Birth Mther s Name Father s Name Parent Cncerns - Please explain any ther cncerns r questins yu have abut yur child Des yur child have any allergies? Yes NO If yes please list belw Des yur child take any medicatins / vitamins / ver the cunter supplements r herbs? Yes NO If yes please list belw Has yur child received any immunizatins? Yes NO If yes please prvide an immunizatin recrd. Educatinal and Scial Histry Please explain any prblems yu have abut yur child in any f the fllwing areas: Appearance/Weight/Height Behavir Grades/learning ability Sexuality

2 Friends_ Hw many hurs per day des yur child watch televisin, surf the internet (nt cunting hmewrk time) r play vide games Hurs per day f exercise Hurs per day f extracurricular activities Please describe any spiritual r religius preferences Are there any bjectins r preferences t medical treatments (i.e prefer hmepathy, prefer nt t immunize, etc.)? Please list all thse living in the child s hme. Name Relatinship t child Date f birth Health status Are there siblings nt listed? If s, please list their names, ages, and where they live. What is the child s living situatin if nt with bth bilgical parents? Lives with adptive parents Jint custdy Single custdy Lives with fster family If ne r bth parents are nt living in the hme, hw ften des the child see the parent(s) nt in the hme Mther s ccupatin Father s ccupatin Childcare situatin

3 Prenatal and Infant Health Histry Place f Birth Maternal age Paternal age Birth weight Length Head circumference Was the baby brn at term? Yes OR weeks Were there any prenatal r nenatal cmplicatins? Yes N Explain Was a NICU stay required? Yes N Explain During pregnancy, did mther Use tbacc Yes N Drink alchl Yes N Use drugs r medicatins Yes N Use prenatal vitamins Yes N Explain Was the delivery Vaginal Cesarean If cesarean, why? Was initial feeding Frmula Breast milk Hw lng breastfed? Did yur baby g hme with mther frm the hspital? Yes N Explain Develpmental Histry (Please nte age at which yur child) Walked Rlled ver Crawled First Wrd Dressed self Drank frm cup Tilet trained General DK = Dn t Knw D yu cnsider yur child t be in gd health Des yur child have any serius illnesses r medical cnditins D yu feel yur family has enugh t eat Des yur child drink caffeine Is there a swimming pl at hme Any smkers at hme Are there smke detectrs at hme Carbn Mnxide detectrs Any pets at hme What is yur water surce Are guns kept in yur hme D all family members use Seat belts/care safety sets D all family members use Helmets when biking Has yur child been t a dentist in the past year Has yur child been t an eye dctr Yes N DK Explain

4 Past Medical Histry Has yur child ever had, Item Yes N Dn t knw Chicken px Frequent ear infectins Prblems with hearing Nasal Allergies Prblems with eyes r visin? Asthma Brnchitis / brnchilitis / pneumnia Heart prblems r murmur Anemia r bleeding prblem HIV Organ transplant Cancer Frequent abdminal pain Cnstipatin Urinary tract infectins Bed wetting past 6 years f age Kidney disease Heart disease High bld pressure Thyrid disease Sleep prblems including snring Skin prblems Frequent headaches Cncussin(s) Seizures Develpmental delay Behavir prblems Schl perfrmance cncerns Drug / alchl use Fr girls prblems with perid / age f menarche Brken bne(s) Hspitalizatins Surgeries Explain Date

5 Review f Symptms Please check the bx if yur child is currently experiencing any f the fllwing: General Fatigue Fever Chills Weight lss/gain Eyes Discharge Eye discmfrt Changes in visin Crssed/Wandering eye Ears / Nse / Thrat Headache Difficulty hearing Recurrent ear infectins Chrnic nasal cngestin / drainage Snring Recurrent sinus infectin Recurrent Sre thrats Nsebleeds Heart Fainting Chest Pain Irregular heart beat Respiratry Wheezing Cugh Pr exercise tlerance Restless sleep Stmach Vmiting Diarrhea Cnstipatin Recurrent stmach aches Pr appetite Excessive hunger/thirst Genital - Urine Bed-wetting Bld in urine Frequent urinatin Painful urinatin Discharge frm Vagina/penis Musculskeletal Jint pain Jint swelling Muscle weakness Muscle pain Neurlgic Seizure Develpmental delay Pr crdinatin Skin Acne Change in mles New mles / skin lesins Hives Rash Easy bruising Endcrine Lss f hair Heat r cld intlerance Pr grwth Pubertal changes Psychiatric Depressin Schl difficulties Inattentin Hyperactivity Behavir issues

6 Family Medical Histry: Have any family members had the fllwing? Item Yes N Dn t knw Childhd hearing lss Allergies Asthma Heart disease (befre 55 years f age) High chlesterl Bleeding disrder Cancer (befre 55 years f age) Liver disease Kidney disease Obesity Diabetes Develpmental delay Seizures / neurlgical disrder Mental illness / depressin Substance abuse Eating disrder Immune prblems Additinal family histry Wh Cmments I have answered the questins n this frm t the best f my knwledge. I understand that t prvide incrrect r incmplete infrmatin abut my child s health and symptms culd place my child s health at risk. Parent/Guardian Signiature Date