Download Pediatric Medical History Update (13

Pediatric Medical History Update (13-17 years)
Patient’s name________________________________________ Date of birth _____________________
Person completing form ________________________________ Relationship to patient _____________
Reason for visit today ___________________________________________________________________
_____________________________________________________________________________________
List all medicines, vitamins, and over the counter medicine patient takes currently
_____________________________________________________________________________________
_____________________________________________________________________________________
New allergies to medicine or food _________________________________________________________
What kind of milk does child drink (whole, skim, soy, etc.) _________________ Cups per day _________
If child drinks juice, how many ounces per day _______ Servings of fruit per day ___________________
Servings of vegetables per day _____________ If child eats meat, servings per day _________________
Concerns about eating habits?____________________________________________________________
Number of hours child sleeps at night ________ Sleeping problems? _____________________________
How often are dental visits? ______________ Any dental problems? ____________________________
How many hours per day does your child watch TV? ____Use computer? ____ Video games _________
Cell phone _________
Any updates to family history? Please indicate which family member has had the following since your
child’s last visit: Alcohol or drug abuse ____________________ Cancer__________________________
Kidney disease ___________ Heart disease _____________ Diabetes ___________ Stroke ___________
High blood pressure ___________ ADHD or ADD ________________ Seizures ____________________
Thyroid problem ________ Psychiatric problem ______________ Asthma or eczema ______________
Other ________________________________________________________________________________
Who lives in household with child?
Name
Age
Relationship to child
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Are parents of child: Married
Partnered
Separated Divorced
Who has custody of child _______________________ Child care situation ________________________
Mother’s occupation __________________________ Father’s occupation ________________________
Any concerns about violence in the home? __________ Guns in home? _______ If so, are they safely
stored? ________
Name of school ______________________________________________ Grade _____________
Any concerns about: School behavior ________________________________________________
Home behavior ___________________________________________________________________
School performance _______________________________________________________________
Relationships with teachers ________________________ With peers _______________________
Does child play sports or do regular exercise? ________ Which type? ________________________
How many days a week? _______ For how long _________________________________________
Does child ride a bike? _____ If so, does child ride a bike helmet? ______
Does child use seat belt consistently? ______ Wear sunscreen when appropriate?______________
Any smokers in the house or car? ______________________________________________________
Does your child have any of the following?
Fever, chills, excess sweating _____________________ Unexplained lumps ____________________
Unexplained weight loss or gain ___________________ Easy bruising or bleeding ________________
Vision problems ________________________________ Hearing problems _____________________
Headaches ____________________________________ Hay fever, allergies _____________________
Weakness, clumsiness ___________________________ Mouth breathing, snoring ________________
Muscle or joint pain _____________________________ Runny nose, cough _____________________
Rash, unusual moles _____________________________ Acne ________________________________
Anxiety, stress, depression _____________________________________________________________
(Girls) Problem with periods ____________________________________________________________
Parent/Guardian signature __________________________________________ Date _______________
Health provider review _____________________________________________ Date _______________