Patient Medical History Form (Pediatric)Patient Medical History Form (Pediatric)Please provide as much information as possible. Mandatory fields are marked *Patient First NamePatient Last NamePatient AgePrefered Name / NicknamePatient Gender- Select -MaleFemaleOthersParent/Guardian First NameParent/Guardian Last NamePhone NumberCurrent CityMedical HistoryBasic information for our recordsName of Referring DoctorDiagnosisDate of DiagnosisMedications or Therapies taken for your DiagnosisBirth HistoryGeneral questions regarding your child's birthInfant DetailsInfant Details Full Term Pregnancy Premature BirthWeeks GestationBirth WeightWent home with Mom?Went home with Mom? Yes NoNICU Stay?NICU Stay? Yes NoNumber of days in NICUSurgical HistoryIf there has been no previous surgery or unknown, skip to next sectionDate / TimeSurgeryProvider/HospitalDate / TimeSurgeryProvider/HospitalHospitalizationsNot including surgeries from previous sectionDate / TimeReasonProvider/HospitalDate / TimeReasonProvider/HospitalOther MedicationsPlease provide any information on current medicationsMedicationDosagePrescribing MD/NPMedicationDosagePrescribing MD/NPCurrent Pharmacy Name/Location:Allergies/ReactionsIncluding medications, pollen, foods, latex, venom, or other products. If none or unknown, please skip to next section.Medication/ProductReactionMedication/ProductReactionFamily HistoryBiological MotherBiological Mother Brother SisterAlive - Current Age?Deceased - Cause?Age at DeathLifetime Diseases?Biological FatherBiological Father Brother SisterAlive - Current Age?Deceased - Cause?Age at DeathLifetime Diseases?Biological SiblingBiological Sibling Brother SisterCurrent StatusCurrent Status Alive DeceasedAlive - Current Age?Deceased - Cause?Age at DeathLifetime Diseases?Biological SiblingBiological Sibling Brother SisterCurrent StatusCurrent Status Alive DeceasedAlive - Current Age?Deceased - Cause?Age at DeathLifetime Diseases?Personal / Family HistoryHas your child or have any close members in your family (not listed above) including your child’s grandparents, aunts, and/or uncles had any of the following medical conditions?► Recurrent Infections Self Family► Immune Deficiencies Self Family► Bleeding/Clotting Self Family► Leukemia/Lymphoma Self Family► Other Cancers Self Family► Allergies/Asthma Self Family► Thyroid Disease Self Family► Bone/Joint Disease Self Family► Autism Self Family► Learning Disorder Self Family► Eczema/Atopic Dermatitis Self Family► Skin Disease Self Family► Bowel Disease Self Family► Heart Disease Self Family► High Blood Pressure Self Family► Lung Disease Self Family► Anxiety/Depression Self Family► Seizures/Epilepsy Self Family► Diabetes Self Family► Tuberculosis Self FamilyCurrent Review of Systems Please check the boxes that your child has or has recently experienced out of the following symptoms.GENERALGENERAL Weight Loss/Gain Fatigue Night Sweats Fevers Hair Loss Sun SensitivityCARDIACCARDIAC Chest Pain Palpitations Swelling/EdemaHEENTHEENT Nasal Congestion Nose/Mouth Ulcers Sore Throat Bleeding Gums Thrush Eye/Ear DrainageRESPIRATORYRESPIRATORY Wheezing Cough Shortness of Breath Sputum ProductionGENITOURINARYGENITOURINARY Frequent Urination Painful Urination Urine Color Change Urine Infections Irregular Menses Heavy Menses Menopausal SymptomsGASTROINTESTINALGASTROINTESTINAL Constipation Diarrhea Abdominal Pain Nausea Black Stool Bloody Stool/tissueMUSCULOSKELETALMUSCULOSKELETAL Joint Pain Joint Redness Joint Swelling Muscle Pain Bone Pain Weakness SKINSKIN Rash Hives Swelling Dry Skin Acne Slow Healing WartsNEUROLOGICNEUROLOGIC Headaches Weakness Numbness/Tingling SeizuresPSYCHOLOGICPSYCHOLOGIC Anxiety Depression Insomnia Memory Loss Poor Academics Attention ProblemsENOCRINOLOGICENOCRINOLOGIC Excessive Thirst Excess Urination Hair Loss Hair Growth Cold/Heat IntoleranceOTHEROTHER Bruising Nosebleeds Swollen Glands/Nodes Neck Stiffness Dental ProblemsSocial HistoryWith whom does your child primarily live with? Does your child live in multiple households?Does your child live in multiple households? Yes NoAre there any pets?Are there any pets? Yes NoNumber and Types of PetsDoes your child attend Daycare/School?Does your child attend Daycare/School? Yes NoIf yes, Name of SchoolCurrent GradeIs child exposed to cigarette smoke?Is child exposed to cigarette smoke? Yes NoIf exposed to cigarette smoke, describeDoes your child follow a special diet?Does your child follow a special diet? Yes NoIf yes, what type of diet?Has your child received a blood transfusion?Has your child received a blood transfusion? Yes NoIf yes, please give detailsHas your child traveled internationally?Has your child traveled internationally? Yes NoIf yes, when/where?Health MaintenanceIf applicableDate of last Vision ScreeningHistory of Abnormal Vision Screen?History of Abnormal Vision Screen? Yes NoIf yes, when/what was done?Date of last Dental ScreeningHistory of Abnormal Teeth?History of Abnormal Teeth? Yes NoIf yes, when/what was done?Federal Race/Ethnicity InformationTo understand what kind of diet your child is or will be eating, and language spoken at home.VegetarianVegetarian Yes NoCountry of OriginPrimary LanguageAny Additional InformationSubmit Form
