New Patient Medical History - 6 Months Old & Over

New Patient Medical History - 6 Months Old & Over
THIS FORM MUST BE COMPLETED AND RETURNED BEFORE 1ST VISIT

*WE DO REQUIRE IMMUNIZATION RECORDS BEFORE WE CAN ADMINISTER ANY VACCINES*

The following is very important to your child's health.

Please complete it accurately and completely.
Child's Name
Birth date

MonthDayYear
Date
Allergies

Please fill in the below forms
Does this child have any Known Drug Allergies? (If Yes - please fill out the following questions)

YesNo
Penicillin (Amoxicillin, Augmentin)

YesNo
Cephalosporins (Omnicef, Keflex, Rocephin, Ceclor, Suprax)

YesNo
Sulpha (Septra/bactrim)

YesNo
Zithromax/erythromycin

YesNo
Other Antibiotics or medications? What reaction? (If Yes, then list name and reaction)

NoYes
Peanuts or other nuts?

NoYes
Milk?

YesNo
Eggs?

YesNo
Seafood?

YesNo
Other foods?

NoYes
Bees / Wasps?

YesNo
Indoor Allergens (pets, molds, dust)?

YesNo
Outdoor Allergens (trees, weeds, pollens)?

YesNo
Latex?

YesNo
Other Allergies

NoYes
Patient - Past Medical History

Please fill in the below forms
Serious accidents or injuries: (If Yes, explain)

NoneYes
Surgeries & Hospitalizations: (If Yes, explain)

NoneYes
Chicken Pox Disease: (If Yes, list age)

NoYes
Frequent ear infections or sinus infections:

YesNo
Frequent sore throats or tonsillitis:

YesNo
Chicken Pox Disease: (If Yes, list any)

NoYes
Allergic rhinitis or other allergy: (If Yes, list any)

NoYes
Asthma, bronchitis, bronchiolitis, pneumonia or croup:

YesNo
Abdominal pain/reflux:

YesNo
Heart disease or heart murmur:

YesNo
Bladder or kidney infection or other urologic problem: (if Yes, explain)

NoYes
Bed-wetting (after age 5):

YesNo
Problems with ears or hearing:

YesNo
Eye conditions / wear corrective lenses:

YesNo
Constipation requiring doctor visits:

YesNo
Chronic or recurrent skin problems/ acne:

YesNo
Anemia or bleeding problem:

YesNo
Past blood transfusion:

YesNo
Frequent headaches:

YesNo
Seizures, developmental delays, ADD/ADHD or other neurological disorders: (if Yes, explain)

NoYes
Mental health concerns: (if Yes, explain)

NoYes
Orthopedic problems: (if Yes, explain)

NoYes
Diabetes:

YesNo
Thyroid, diabetes or other endocrine problems: (if Yes, explain)

NoYes
If female, any problems with periods? (if Yes, explain)

NoYes
If female, have menstrual periods started?

YesNo
Use of alcohol or drugs: (if Yes, explain)

NoYes
Emotional or mental health problems: (if Yes, explain)

NoYes
Other significant issues: (if Yes, explain)

NoYes
Has your child had a serious reaction to immunizations? (if Yes, explain)

NoYes
Family - Past Medical History

Follow each question listed below and if you mark yes, you will receive another question following the previous that must be answered.
Nasal allergies or other allergies

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Asthma/lung Disease

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Heart Disease or heart condition

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
High blood pressure

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
High cholesterol

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Diabetes or other endocrine problem

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Cancer

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Anemia

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Bleeding disorder

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Epilepsy or convulsions

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Mental retardation or developmental disorders

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Neurological disorder including

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
ADHD/ADD

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Liver disease

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Other GI disease / disorder

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Kidney disease

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Bed-wetting (after age 10)

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Hearing impairment

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Vision impairment or eye disorder

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Immune problems, recurrent infections or HIV-AIDS

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Alcohol Abuse

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Drug Abuse

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Mental Illness

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Tuberculosis

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Migraine Headaches

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Thyroid Disease

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Intestinal ulcers, colitis, gast, reflux

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Autoimmune disorder: lupus or rheumatoid arthritis

YesNo
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
If YES - Please check which biological relative

MomDadSiblingMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Other Issues & Biological Relative
Social History
Does the child live with both mother and father in the same house? (If other, explain the situation and the visitation status of non-custodial parent)

YesOther
Are there siblings?

YesNo
Are there pets in the home?

YesNo
Are there smokers in the home? (If other - explain who)

NoOther
Are there guns in the home? (If other - explain)

NoOther
Are guns locked and kept separate from ammunition? (If other - explain)

NoOther
Other Issues:
Where was your child born?
Is child adopted or fostered?

YesNo
Birth History
Baby's Birth Weight: Pounds
Baby's Birth Weight: Ounces
Which kind of birth was the baby?

Vaginal BirthC-section
Was the baby:

Full termEarlyLate
If early, how many weeks gestation?
Did the baby have any problems right after birth?
Did mother have any problems with the pregnancy?
Developmental History
Are you concerned about your child's physical development?

NoYes
Are you concerned about your child's attention span?

NoYes
Has he/she failed or repeated a grade?

NoYes
How is your child's behavior in school?
What kind of grades does he/she make in academic subjects?
Is he/she in a special or resource classes?
When did your child first sit up?
When did your child first crawl?
When did your child first walk?
When did your child speak their first sentence?
When was your child toilet trained?
Current Medications and Dosage: (include any over the counter, herbal, or supplements)
Does your child see any specialists? If so, who and where?
Is there anything else regarding your child's health that you think we should know that has not already been asked?
WE DO REQUIRE IMMUNIZATION RECORDS BEFORE WE CAN ADMINISTER ANY VACCINES

THIS FORM MUST BE COMPLETED AND RETURNED BEFORE 1ST VISIT
I attest that all the medical history information is true and correct to the best of my knowledge:
Signature

Clear
Relationship to patient
Date

MonthDayYear
Date
Print Name
Should be Empty:

New Patient Medical History - 6 Months Old & Over

THIS FORM MUST BE COMPLETED AND RETURNED BEFORE 1ST VISIT

Allergies

Patient - Past Medical History

Family - Past Medical History

Social History

Birth History

Developmental History

WE DO REQUIRE IMMUNIZATION RECORDS BEFORE WE CAN ADMINISTER ANY VACCINES