Health History (under 3)
Last Name
First Name
Nickname
Date of Birth
Questions Pertaining to Mother’s Pregnancy
How many times has
mom been pregnant?
How many children
does she have?
How many weeks
was this pregnancy?
Were maternal ultrasounds normal?
Yes
No
While pregnant were alcohol, drugs or cigarettes used?
Yes
No
Any infections during pregnancy (including Group B Strep)?
Yes
No
Breech in third trimester?
Yes
No
Any complications with pregnancy?
Yes
No
Questions Pertaining to Mother’s Delivery
Type of delivery
Vaginal
C-section
Was the delivery induced?
Yes
No
Was the delivery
Routine
Emergent
Any complications with or after delivery?
Yes
No
Time of Birth
Birth Weight
Birth Length
Mother’s Blood Type
Child’s Blood Type
Hearing Screen
Pass
Fail
Type of feeding
Breast
Formula
Formula Name
Hepatitis B Vaccine at Birth?
Yes
No
Date Given
Discharge Date
Birth Weight
Birth Hospital
Obstetrician
Pediatrician (in hospital)
Minor/Child’s Health History
Minor/Child’s Previous Physician
City/State
Phone
Has minor/child had any history of/or difficulty with any of the following?
Acne
ADD/ADHD
Allergies
Anemia
Anxiety
Asthma
Autism
Auto Immune Disorders
Bed Wetting
Birth Defects
Bleeding Problems
Blood Clots
Cancer
Chicken Pox
Constipation
Developmental Delay
Diabetes
Diarrhea
Ear Infections, recurrent
Eczema
Epilepsy
Fainting
Genetic Disorders
GERD (Reflux)
Hearing Problems
Heart Disease
High Blood Pressure
High Cholesterol
Hip Disorders
Immuno-compromised
Kidney Disease
Marfan Syndrome
Mononucleosis
Obesity
Pneumonia
Prematurity
Seizures
Sinus Problems
Speech Delay
Strep Throat, recurrent
Stroke
Thyroid Disease
Tonsillitis
Tuberculosis
Urinary Tract/Bladder Infections
Vesicoureteral Reflux
Vision Problems
Other
Immunizations up-to-date?
Yes
No
Medications
Minor/Child is on
Allergies
of Minor/Child
Hospitalizations and/or Surgeries
Date
Reason(s)
Hospital
Add another?
Date
Reason(s)
Hospital
Add another?
Date
Reason(s)
Hospital
Family History
Has member of the family or close relative had any of the following?
ADD/ADHD
Alcoholism
Allergies
Anxiety
Asthma
Autism
Auto-immune Disorders
Bed-wetting
Bipolar
Bleeding Problems
Blood Clots
Cancer
Depression
Diabetes
Drug Abuse
Eczema
Gender Dysphoria
Genetic Disorders
GERD (Reflux)
Hearing Problems
Heart Disease
High Blood Pressure
High Cholesterol
Hip Disorders
Immuno-compromised
Kidney Disease
Marfan Syndrome
Obesity
Seizures
Stroke
Sudden or unexpected death
Tuberculosis
Urinary Tract/Bladder Infections
Vesicoureteral reflux
Other
Social History
Who is living in your home?
What is your child's sleep position?
Back
Stomach
Side
Does your child use a
Car seat
Seat belt
Is your child in daycare?
Yes
No
Are there any smokers in the house?
Yes
No
Do they smoke
Inside
Outside
Are there any firearms in the house?
Yes
No
Are they locked up?
Yes
No
Was your house built before 1978?
Yes
No
Is there any peeling paint in the house?
Yes
No
Do you have smoke detectors and a fire escape plan?
Yes
No
Signature of Parent or Legal Guardian
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Date