CHILD HEALTH HISTORY

Name of patient _____________________________  DOB ______________________

HISTORY OF PREGNANCY WITH THIS CHILD:
During which month of pregnancy did you first see the doctor? ______ Month;  How long was your pregnancy? ______ Months        
Where was baby born? ______________________  If baby was born at home, were blood tests for newborn screening done?   Yes   No
Did you have any illnesses or problems? (including sexually transmitted or other communicable diseases)        YES/NO        
Did you use any non-prescribed drugs? (tobacco, alcohol, “street drugs:, over-the-counter or home remedies)    YES/NO
Did you take any medications prescribed by your doctor?  YES/NO        Did the baby go home with you from the hospital? YES/ NO
Did you have a difficulty/abnormal delivery/C-section?        YES/NO        Was more than one baby born?                  YES/NO
Did the baby have any problems during the 1st week of life? YES/NO    Did baby receive any shots for Hepatitis B?             YES/NO

CHILD’S HISTORY:  
Male/Female   M/F.     Is this child adopted?   YES/NO;       Birth Weight: ______pounds ______ounces         Length: ______inches

Has your child ever had (Please circle Yes or No):
Measles, Chickenpox, Mumps, Rubella        YES        NO        Vomiting after eating, refusal to eat    YES        NO
Tuberculosis or positive TB Test                     YES        NO        Muscle, joint or bone problems          YES        NO
Tonsillitis/Sore Throat                                        YES        NO        Skin problems                                       YES        NO
Problems with eyes or vision                            YES        NO        Headaches or dizziness                      YES        NO
Problems with ears or hearing                         YES        NO        Convulsions, seizures, epilepsy        YES        NO
Difficulty breathing/snoring at night                  YES        NO         Diabetes                                                YES        NO
Heart problems        YES        NO                                                    Thyroid problems                                  YES        NO
Asthma, bronchitis, or pneumonia                   YES        NO        Allergies                                                  YES        NO
Anemia, bleeding problems, blood transfusions YES/NO       Problems with development of school performance   YES        NO
Stomachaches                                                     YES        NO         Serious illness or accident                  YES        NO
Diarrhea, Soiling self with stool                        YES        NO        Surgery or hospitalization                     YES        NO
Bladder Kidney Problems, Wetting self or bed      YES/NO       (GIRLS) Has she stared her periods?                            YES        NO
Constipation             YES        NO                                                    (GIRLS) Are there problems with her periods?              YES        NO

FAMILY HISTORY:  
Does mother (M), father (F), brother (B), sister (S), aunt (A), uncle (U), or grandparent (GP) have:
                                                   Which Family Member?                                                                                   Which Family Member?
YES        NO        Diabetes                                                                YES        NO        High blood pressure        
YES        NO        Epilepsy or convulsions                                      YES        NO        Bleeding disorder        
YES        NO        Mental retardation                                                 YES        NO        Tuberculosis        
YES        NO        Heart disease                                                        YES        NO        Allergy        
YES        NO        Cancer                                                                     YES        NO        Lung or breathing problems        
YES        NO        Kidney or urinary disease                                    YES        NO        Eye disorder        
YES        NO        Bone or joint problems                                         YES        NO        Ear disorder        

PARENT INFORMATION:
                   Mother:                       Father:
Age:                         
Height:                         
Occupation:                                                                                              

HOUSEHOLD INFORMATION:  Number of people in home         
Are both parents living in the home?  YES/NO;
Does anyone in the home smoke, or use drugs or alcohol?  YES/NO;
Language spoken in the home:                 
Do you live in a:  House    Apartment    Mobile Home     Shelter     Homeless


Patient Identification:

Signature:  __________________________________  Date: _____________  Relationship to Child: _________________        

Reviewer’s Signature: _________________________  Date: _____________
CHILD HEALTH HISTORY, English