Northpointe Pediatrics

Health History (under 3)

Questions Pertaining to Mother’s Pregnancy
Were maternal ultrasounds normal?   

While pregnant were alcohol, drugs or cigarettes used?   

Any infections during pregnancy (including Group B Strep)?   

Breech in third trimester?   

Any complications with pregnancy?   

Questions Pertaining to Mother’s Delivery
Type of delivery   

Was the delivery induced?   

Was the delivery   

Any complications with or after delivery?   

Hearing Screen   

Type of feeding   

Hepatitis B Vaccine at Birth?   

Minor/Child’s Health History
Has minor/child had any history of/or difficulty with any of the following?

Immunizations up-to-date?   

Hospitalizations and/or Surgeries

Add another?   
Family History
Has member of the family or close relative had any of the following?
Social History
What is your child's sleep position?   

Does your child use a   

Is your child in daycare?   

Are there any smokers in the house?   

Are there any firearms in the house?   

Was your house built before 1978?   

Is there any peeling paint in the house?   

Do you have smoke detectors and a fire escape plan?   

Signature of Parent or Legal Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
LuxSci helps ensure HIPAA-compliance for email and web services.