Northpointe Pediatrics

Health History (3 and over)

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?
Sports Participation Questions
Has your child ever fainted/passed out DURING exercise?   

Has your child ever fainted/passed out or nearly passed out AFTER exercise?   

Has your child ever had chest discomfort, pain or pressure DURING exercise?   

Does your child’s heart race (palpitations) or skip beats DURING exercise?   

Have you been told that your child has heart disease, a heart murmur, high blood pressure or high cholesterol?   

Has any family member died of heart problems or a sudden and unexpected death before age 50?   

Does anyone in your family have Marfan’s syndrome?   

Social History
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?   

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