Download Pediatric Health History: Ages 1-6

Pediatric Health History: Ages 1-6
Patient Name:
Patient Gender: Male / Female
Patient Date of Birth:
Patient’s Age:
Patient Social Security Number:
Today’s Date:
Birth History
Did mother receive regular prenatal care?
Birth weight:
Was the pregnancy full term?
Type of delivery: (ex: vaginal or C-section)
If C-Section, please explain why:
How long did the child stay in the hospital after birth?
Please list birth complications, if any.
Is/was the child breast fed?
If yes, until what age?
Family History
For each of the following blood relatives, please describe the health status, severe illness(es), death and age at death as they
apply.
Father
Mother
Sister(s)
Brother(s)
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Pediatric Health History: Ages 1-6
Patient Name:
Status of child’s parents: (choose which applies)
Married, Never Married, Divorced, Single Parent
Who lives at home with the child? Please list all people and their relationships to the child.
Is child care…?
Provided at home, Provided away from home
Please specify if blood relatives have had any of the following. Choose all that apply:
Heart disease, High Blood Pressure, Kidney Disease, Allergies/Asthma, Cancer, Deafness, Diabetes,
Mental/Emotional Problems, Sickle Cell, Seizures, Other hereditary condition, Tuberculosis, HIV/Aids or
Immune Problems
If other, please specify:
Medical History
Please list hospitalizations, operations, serious illnesses or accidents (with dates):
Please rate child’s general health
Excellent, Good, Fair, Poor
Please describe why you rated as above:
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Pediatric Health History: Ages 1-6
Patient Name:
Please rate child’s diet:
Excellent, Good, Fair, Poor
Please describe why you rated as above:
Has the child been seen by a dentist?
How recently?
Child’s grade (level) in school
At what age did the child reach the following milestones? If the child has not reached the milestone, please type “N/A”
Sit alone:
Walk alone:
Say words:
Toilet train:
Medications
Please list all current medications:
Medication Name
Dosage
Frequency
Immunizations
Are the child’s immunizations up to date? (Please bring immunization records to visit)
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Status (Active)?
Pediatric Health History: Ages 1-6
Patient Name:
Exposure to Smoke
Please specify if any of the following apply:
No smokers in household, Family members smoke indoors, Family members smoke outdoors only,
Caregiver smokes indoors, Caregiver smokes outdoors only, Other exposure to second hand smoke
If smokers, please specify relationship above
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