Childhood Health History Child’s Name: Sex: Male Female Birthdate: Today’s Date: Child’s Health History Name of Doctor/Clinic: City/State: Phone number: Were there any significant problems during pregnancy or birth? No Yes, Please explain: Has your child had surgery or been hospitalized? No Yes, Please explain:
Infectious Diseases History: Family History: Please indicate any family Has your child had the following member who has the following (parent, diseases: grandparent, sibling, etc):
child health record: form 2b, health history (continued) person interviewed: iauie nrf iltirvicuiw.-date: _ relationship: titi :. physical, psychological, and social development these questions will help us understand your child better and know what is usual for him/her and what
NEW PATIENT HEALTH HISTORY FORM PEDIATRIC REASON FOR VISIT RELATIONSHIP TO CHILD CHILD’S LIVING SITUATION If one or both parents are NOT living in the home, how often does the child see the parent? NAME DATE OF BIRTH HEALTH PROBLEMS BIOLOGICAL FAMILY ADOPTIVE PARENTS FOSTER FAMILY JOINT CUSTODY SINGLE CUSTODY OTHER (describe) BIRTH WEIGHT LBS OZ
Does the child have a history of any other illnesses? If yes, please list: Has the child ever received a general anesthetic? Does the child have any inherited problems? , .,,,, 9. Does the child have any speech difficulties? 10. Has the child ever had a blood transfusion? , 11 Is the child physically, mentally, or emotionally impaired? ..,,,, 12.
Has your child ever been treated for or diagnosed with: (explain) Family History Asthma or reactive airway disease ____________________ Wheezing or bronchiolitis ____________________________
MIT Medical Department Pediatrics History Form Dear Parent: This is a health questionnaire on your child. Please complete this form. Bring it with you at the time of an appointment. Date completed: Child’s Name: Date of Birth: Contact Information for Parent 1 Name: Email:
Please print, complete, and bring to your appointment Pediatric Health History Form Date: _____ Child’s Name: _____ Date of Birth: _____ Age: _____ Present Health Concerns: _____
Child Health/Dental History Form Child’s History Yes No 1. Is the child taking any prescription and/or over the counter medications or vitamin supplements at this time? ..... . 1. If yes, please list: _____
Does the patient have a past history or a current disease, problem, or condition involving any of the following? If yes, check all that apply. Does the patient have allergies or develop a reaction to medications, foods, or environmental allergens? If yes, please specify: