Past/family history form

Past Medical History and Family History

Patient Name_____________________________Date____________________

Date of Birth________________________

Mom's name_________________________Dad's name__________________________

Child's birth history

Pregnancy Complications:__________________________________________________

Smoking? Yes  No

Alcohol?  Yes  No

Other drugs?  Yes No

Medications?____________________________

Infections?_____________________________

Gestation_______weeks, Delivery_____________________________

Birthweight______________Apgars __________@ 1 min______________@5 min

Child's Past Medical History:

Chronic medical conditions________________________________________________

Medications__________________________________________________________

Allergies_____________________________________________________________

Hospitalizations________________________________________________________

Surgeries_____________________________________________________________

Developmental concerns___________________________________________________

Injuries_______________________________________________________________

Other________________________________________________________________

Social History:

Lives with_____________________________________________________________

Parents ______Married_____Separated_____Divorced_____Single_____Other__________

Dad's occupation_________________________________________________________

Mom's occupation________________________________________________________

Exposure to tobacco smoke?  Yes   No  Exposure to guns?  Yes   No

Family History:

Is the child adopted?________if yes, is any of the family history known?________

Answer the following for child's parents, grandparents, aunts, uncles, first cousins

Y  N                                         Affected family Member(s)

Y  N  Allergies_______________________________________________________

Y  N  Arthritis_______________________________________________________

Y  N  Asthma________________________________________________________

Y  N  Cancer: type_____________________________________________________

Y  N  Hearing loss_____________________________________________________

Y  N  Recurrent ear infections_____________________________________________

Y  N  Recurrent sinus infections___________________________________________

Y  N  Diabetes (Type 1 or Type 2?)__________________________________________

Y  N  Substance abuse/alcohol abuse________________________________________

Y  N  Gastrointestinal disorders____________________________________________

Y  N  Gastroesophageal reflux disease________________________________________

Y  N  Ulcers__________________________________________________________

Y  N  Celiac disease_____________________________________________________

Y  N  Inflammatory bowel disease___________________________________________

Y  N  Heart disease_____________________________________________________

Y  N  Hyperlipidemia (high cholesterol/triglycerides)______________________________

Y  N  High blood pressure_________________________________________________

Y  N  Kidney disease_____________________________________________________

Y  N  Recurrent urinary infections____________________________________________

Y  N  Ureteral reflux______________________________________________________

Y  N  Mental health disorders________________________________________________

Y  N  Depression_________________________________________________________

Y  N  Anxiety___________________________________________________________

Y  N  ADHD____________________________________________________________

Y  N  Neurologic disorders__________________________________________________

Y  N  Siezures___________________________________________________________

Y  N  Developemental delay/disorders__________________________________________

Y  N  Thyroid disease_____________________________________________________

Y  N  Vision problems_____________________________________________________

Y  N  Strabismus (Lazy eye)_________________________________________________

Y  N  Immune deficiencies__________________________________________________

Y  N  Vascular disease_____________________________________________________

Y  N  Heart attack or stroke in person less than 55 years of age______________________

________________________________________________________________

Y  N  Overweight/Obesity___________________________________________________

Y  N  Sudden death_______________________________________________________

Y  N  Genetic disorders_____________________________________________________

Y  N  Other_____________________________________________________________