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Pediatric History Form
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Current Weight
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Height
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Name of Primary Care Physician
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Date of Last Physical Exam
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Other Physicians your child is seeing? Name:
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Telephone Number
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Reason for today’s visit?
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Date of onset/injury
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Birth History
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Was your child full term or Premature?
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Birth weight?______lbs
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_____oz
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Number of Weeks Gestation
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Medical Problems of Mother during Pregnancy?
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Did Mother Smoke?
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Drink Alcohol?
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Recreational Drugs?
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Medications taken during Pregnancy?
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Past Medical History
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Circle any Condition that your child has had:
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If cancer, please mention type?
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If other, please mention
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Past Surgical History
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Date
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Surgery/Hospitalization
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Date
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Surgery/Hospitalization
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Date
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Surgery/Hospitalization
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Child had a Reaction to General/Local Anesthesia
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Has your child ever received a Blood Transfusion
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Last Immunization?
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Are Immunizations up to date
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Do Household Members Smoke?
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How many people live in household including you?
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Adults______
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Children______
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Pets_______
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Is Child in Day Care
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Does Child receive Speech Therapy?
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Other Services received such as Early Interventi
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If Yes Please Explain
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Family Medical History
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Cancer
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Relative
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Cleft Lip or Palate
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Relative
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Heart Disease:
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Relative
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Stroke:
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Relative
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Sickle Cell Anemia:
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Relative
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Diabetes:
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Relative
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Asthma
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Relative
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Seizure
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Relative
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Other? Specify
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Review of Systems
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If there is a weight change, up or down
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Girls-Date of Last Menstrual Period?
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First day of Last Menstrual Period?
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Physical Exam
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HEENT
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HEENT Comments
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Cardiovascular: Regular rate and rhythm)
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Cardiovascular Comments
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Lungs: CTA bilaterally
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Lungs Comments
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Breasts
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Breasts Comments
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