PATIENT MEDICAL HISTORY FORM

Tri-County Pediatrics Associates, P.C.

Today's date

First name

Last name

Date of Birth

Email

Phone Number

Mother's Name

Previous Pediatrician address

Previous Pediatrician phone #

PREGNANCY AND BIRTH HISTORY

Mother's age at child's birth

Illness or problems during pregnancy

Medications during pregnancy

Smoking/alcohol/street drugs during pregnancy

Was baby born on time/early/late? If so # of weeks early/late?

Type of delivery

Birth weight

Complications/problems with labor/delivery

Problems with baby at or after birth

Feeding

breast

bottle

combination of both

CHILD'S PAST MEDICAL HISTORY

Significant illnesses/ongoing health issues

Hospitalizations

Serious Injuries

Immunizations up to date?

yes

no

Do you have a record of immunizations?

yes

no

Allergies (medications/foods/animals/insects)

Medications taken on regular basis? (incl. vitamins/herbals/supplements)

SOCIAL HISTORY

Are parents:

Married

Separated

Divorced

Deceased

Mother's occupation

Father's occupation

Who else lives at home?

Main daytime care

Pets in home?

Age of home? (if known)

Smokers in home?

yes

no

Weapons in home?

yes

no

Language other than English spoken at home

Lead poisoning in other children?

yes

no

FAMILY MEDICAL HISTORY

Mother's age

Mother's health issues

Father's age

Father's health issues

Please list all siblings (name, age, health issues)

List all relatives of child who have/had any of the following:

(Parents/Grandparents/Aunts/Uncles/Cousins)

Anemia/Blood disorder

Asthma

Allergies

Mental Retardation/Developmental Issues

Diabetes

High Blood Pressure

High Cholesterol Level

Cancer

Epilepsy/Seizures

Drug/Alcohol Problem

Mental Illness

Arthritis

Kidney/Urinary Disorder

Thyroid Disease

Cystic Fibrosis

Muscular Dystrophy

Obesity

Learning Disorder

Migraine

Birth Defects

Early Deafness

Sudden Infant Death (SIDS)

Have any of your children died?

Created with

PATIENT MEDICAL HISTORY FORM

Tri-County Pediatrics Associates, P.C.

Today's date

First name

Last name

Date of Birth

Email

Phone Number

Mother's Name

Previous Pediatrician address

Previous Pediatrician phone #

PREGNANCY AND BIRTH HISTORY

Mother's age at child's birth

Illness or problems during pregnancy

Medications during pregnancy

Smoking/alcohol/street drugs during pregnancy

Was baby born on time/early/late? If so # of weeks early/late?

Type of delivery

Birth weight

Complications/problems with labor/delivery

Problems with baby at or after birth

Feeding

breast

bottle

combination of both

CHILD'S PAST MEDICAL HISTORY

Significant illnesses/ongoing health issues

Hospitalizations

Serious Injuries

Immunizations up to date?

yes

no

Do you have a record of immunizations?

yes

no

Allergies (medications/foods/animals/insects)

Medications taken on regular basis? (incl. vitamins/herbals/supplements)

SOCIAL HISTORY

Are parents:

Married

Separated

Divorced

Deceased

Mother's occupation

Father's occupation

Who else lives at home?

Main daytime care

Pets in home?

Age of home? (if known)

Smokers in home?

yes

no

Weapons in home?

yes

no

Language other than English spoken at home

Lead poisoning in other children?

yes

no

FAMILY MEDICAL HISTORY

Mother's age

Mother's health issues

Father's age

Father's health issues

Please list all siblings (name, age, health issues)

List all relatives of child who have/had any of the following:

(Parents/Grandparents/Aunts/Uncles/Cousins)

Anemia/Blood disorder

Asthma

Allergies

Mental Retardation/Developmental Issues

Diabetes

High Blood Pressure

High Cholesterol Level

Cancer

Epilepsy/Seizures

Drug/Alcohol Problem

Mental Illness

Arthritis

Kidney/Urinary Disorder

Thyroid Disease

Cystic Fibrosis

Muscular Dystrophy

Obesity

Learning Disorder

Migraine

Birth Defects

Early Deafness

Sudden Infant Death (SIDS)

Have any of your children died?

Created with

PATIENT MEDICAL HISTORY FORM