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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 _______________