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The Pediatric Clinic UPDATED Medical History Information
Complete and accurate information allows us to provide better care for your child
*Patient’s Name (use one form per child): ____________________________ *Date of Birth: _____________
*What is your preferred method for us to contact you? Phone, text, email? Let us know.
*Contact Information: _____________________________________________________________________
***BE SURE TO CONTACT US WITH CHANGES.***
*Preferred Pharmacy: ___________________________ and if more than one, location: __________________
THIS PATIENT’S PAST MEDICAL HISTORY
*Any allergies to any medications? No
Yes If yes, which medications and what was the reaction?
_______________________________________________________________________________________
*Is this child taking any medications, breathing treatments, vitamins, supplements?
No
Yes
If yes, list the medication(s) and how often used (daily or only as needed): _______________________
______________________________________________________________________________________
*In the past year, has your child been diagnosed with any of the following?:
o
o
o
o
o
o
o
o
o
o
NO NEW CONCERNS
Adopted
Anemia
Asthma/Wheezing
ADHD
Behavior Problem
Bleeding Disorder
Cancer __________
o
o
o
o
o
o
o
o
Chicken Pox
Dental Problems
Diabetes
Food Allergies
Frequent Illnesses
Growth Problem
Heart Defect or Murmur
HIV
o
o
o
o
o
o
o
o
Infections
Kidney Disease
Learning Disability
Prematurity
Seasonal Allergies
Seizures
Stomach Problems
Urinary Tract Infection
OTHER: __________________________________________________________________________
SERIOUS INJURY / HOSPITALIZATIONS / ANY SURGERY (including ear tubes):
________________________________________________________________________________________________________
*Anything else we should know: _________________________________________________________________________________
SOCIAL HISTORY
This child lives with (circle): mother father siblings
stepsibling
half-sibling
foster parent
grandmother grandfather aunt/uncle
stepmother stepfather
other: _____________________
FAMILY MEDICAL HISTORY
In the past year, has there been any medical problems in your family history that we should know about?
Include relationship to this child: __________________________________________________________________
_________________________________________________________________________________________
Person completing form: _____________________________________________________
SIGNATURE AND RELATIONSHIP
____________
TODAY’S DATE