Fill in Family Medical History Form for Your Child
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Microsoft Give-and-take - 76 KB]
Child's Proper name
_________________________________________________________
_________________________________________________________
_________________________________________________________
Today's Engagement: ___________________________________
Date of Nascency: ___________________________________
Child's Address
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________________
Filling out this form
- Answering these questions will help your doctor understand your child's health and how best to treat your child.
- If y'all need assist filling out this class:
- Bring this form with you to your appointment and a nurse volition help you.
OR
- Call the dispensary at [555-1212 ext. 123] earlier your appointment and someone can help you over the phone.
- Bring this form with you to your appointment and a nurse volition help you.
Bring to your appointment:
We look forrad to working with yous!
Full general Information
What is the child's sex? ___ Female ___ Male person
Kid's Date of Birth______________________ current age ___________________________________
Is your kid adopted? ___ No ___ Aye If yes, at what age? ___________________________________
Who is filling out this form?
___ Female parent
___ Father
___ Other guardian (please explain relationship to child): ________________________
___ Other (please explain): ______________________________________________________________________
The child'due south parents are:
___ Single ___ Married ___ Divorced ___ Separated but not divorced
___ Widowed ___ Living together merely not married ___ Unknown
| Main adult contact for kid | Other adult contact for child |
|---|---|
| Name: ________________________ | Name: ________________________ |
| Relation to kid: ___ Mother ___ Male parent ___ Other: ________________________ | Relation to kid: ___ Female parent ___ Begetter ___ Other: ________________________ |
| Address: ___ Same every bit child's Street address: ____________________ ________________________ City: ________________________ State: _____________________ Null: ____________________ | Address: ___ Same equally child's Street accost: ____________________ ________________________ Metropolis: ________________________ Land: _____________________ Zip: ____________________ |
| Home Phone: | Dwelling house Phone: |
| Prison cell Phone: | Cell Telephone: |
| Work Telephone: | Work Phone: |
Today's Health Problems
1. Listing your child's main health problems (or reasons for visiting the dispensary).
___ Routine checkup
___ Immunizations (shots)
___ A health problem (please specify): __________________________________________________________________________________________________)
___ Switching doctors (concluding dr.): __________________________________________________________________________________________________)
two. How well do you feel your child acts or behaves?
___ Poor ___ Fair ___ Adept ___ Very Skillful ___ Fantabulous
Medical History
3. Has your child ever been a patient in a hospital (other than a few days subsequently birth)?
___ No (If no, go to question #4.)
___ Yes (If yes, explicate why and when beneath.)
| My child was in the hospital because: | When |
|---|---|
| Example: Bike accident | five years old |
4. Is your child taking any prescription medicines?
___ Aye—Delight listing the kid's medicines below or ___ I brought my kid's medicines.
___ No. My child does non have any prescription medicines. (If no, become to question #5.)
| Proper noun of medicine | Corporeality / size of pill | How many pills or doses practise yous take at |
|---|---|---|
| Case: Dexadrine | 10 mg | 1 morning ___ noon ___ dinner i bed |
| ___ morning ___ noon ___ dinner ___ bed | ||
| ___ morning time ___ noon ___ dinner ___ bed | ||
| ___ morning time ___ noon ___ dinner ___ bed | ||
| ___ morn ___ noon ___ dinner ___ bed | ||
| ___ forenoon ___ noon ___ dinner ___ bed | ||
| ___ forenoon ___ noon ___ dinner ___ bed |
(Please apply the back of this form if yous have more than prescription medicines.)
5. What over-the-counter medicines, does your child have regularly?
___ Vitamins
___ Herbal medicine (please list) ________________________________________________________________________
___ Other (delight listing) __________________________________________________________________________________
___ None, my child does not take any over-the-counter medicines regularly.
6. Does your kid have any allergic reaction (bad effects) from any of the following? (Check all that apply.)
___ Outside or Indoor allergies (for instance: grass, pollen, cats …)
___ Food Allergies (for example: peanuts, milk, wheat …)
___ Medicine or shots (immunization). (Please list below.)
___ No, my kid has no allergies that I know of.
| Medicine child is allergic to | What happens when I take that medicine |
|---|---|
| Example: Amoxicillin | Diarrhea (runny poop) |
7. Has your kid had any of the following diseases?
| Measles | ___ Yes | ___ No | ___ Don't Know |
| Mumps | ___ Aye | ___ No | ___ Don't Know |
| Chicken Pox | ___ Aye | ___ No | ___ Don't Know |
| Whooping Cough | ___ Yes | ___ No | ___ Don't Know |
| Rubella | ___ Yes | ___ No | ___ Don't Know |
| Rheumatic Fever | ___ Yeah | ___ No | ___ Don't Know |
| Carmine Fever | ___ Aye | ___ No | ___ Don't Know |
8. Please check whatever of the following medical problems that your child has ever had.
| Has your kid ever had: | |
| Ear infections | ___ Yes ___ No |
| Nose problems (sinus infections, nose bleeds) | ___ Yes ___ No |
| Eye problems (blurry vision, need to wear glasses) | ___ Yes ___ No |
| Hearing issues | ___ Yes ___ No |
| Mouth or throat problems (Strep pharynx, swallowing problems) | ___ Yes ___ No |
| Diarrhea (having frequent and runny bowel movements/poop) | ___ Yes ___ No |
| Constipation (problems having a bowel motility /poop) | ___ Aye ___ No |
| Problems peeing (bed wetting, hurting when peeing) | ___ Yes ___ No |
| Back problems (crooked back, back hurting) | ___ Yes ___ No |
| Growing pains (os or torso pains due to growing) | ___ Yes ___ No |
| Musculus and bone problems (weak muscles, pain in joints) | ___ Yes ___ No |
| Skin problems (acne, flaking skin, rashes, hives) | ___ Yeah ___ No |
| Seizures (shaking fits) | ___ Yes ___ No |
| Add/ADHD (problems paying attention, sitting even so) | ___ Aye ___ No |
| Sleeping problems (falling or staying asleep) | ___ Yes ___ No |
| Breathing issues (cough, asthma) | ___ Yes ___ No |
| Warts | ___ Aye ___ No |
| Jaundice (yellowish skin) | ___ Yeah ___ No |
Shots
9. Has your child received immunizations (shots) in the past?
___ No (If no, go to question #x.)
___ Yes
If yes, have you given this office a re-create of the immunization (shots) records?
___ Yeah (If no, go to question #10.)
___ No
If not, delight give us the proper noun of the doctors' offices or clinics where your child has received these shots then we can go the records.
Doctor'due south function/clinic name: ____________________________________________________________
Doctor'due south office/clinic phone number: ____________________________________________________________
Virtually Mom When Pregnant
The following questions are about the female parent of the child during pregnancy and nascency.
If yous exercise non know about the pregnancy of the female parent, cheque here ___ and go to #17.
10. What was the general wellness of the mother during pregnancy?
___ Excellent ___ Practiced ___ Fair ___ Poor ___ Unknown
11. Were whatever of the post-obit used during pregnancy?
___ Cigarettes
___ Booze
___ Illegal drugs (which ones? ___________________________________________)
___ Prescription drugs (which ones? ______________________________________)
___ None of the higher up
12. Did the female parent have any of the following weather or bug during pregnancy?
___ Preeclampsia (loftier blood pressure level)
___ Diabetes (sugar)
___ Emotional stress
___ Injury or serious illness
___ Unexpected haemorrhage or spotting
___ Other ____________________________________________________________
13. Was the birth:
___ On the due engagement
___ Before the due appointment (by how much ____________________________________________________________)
___ After the due date (by how much ____________________________________________________________
fourteen. Was the birth: ___ Vaginal ___ C-Department (surgical cut in the stomach?)
15. Were whatever of the following used?
___ Hurting medicine during nascence (epidural)
___ Tool to help pull baby out (forceps or vacuum)
___ None
sixteen. Were there any issues during the birth? ___ Yes ___ No
If aye, delight explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Virtually the Child Equally a Infant
17. Was/is the kid breastfed? ___ Yes ___ No
If aye, how long ____________________________________________________________
xviii. In the offset 2 months after birth, did the child have:
___ Jaundice (yellow skin)
___ Colic (upset stomach, crying)
___ Breathing issues
___ Other ____________________________________
___ None of the above
19. At what age did the kid begin to clamber? ____________________________________
twenty. At what age did the child brainstorm to sit down up? ____________________________________
21. At what historic period did the child begin to walk? ____________________________________
22. At what historic period did the child get his/her first molar? ____________________________________
23. At what age did the child began to say words (mama, dada)? ____________________________________
24. How would you rate your child's health in his or her first year of life?
___ First-class ___ Very Expert ___ Proficient ___ Off-white ___ Poor ___ Unknown
In School and At Home
25. Does the kid become to school or daycare? ___ Yes ___ No
If yep, what is its proper noun?________________________________________________________________________
26. If your child goes to school or daycare, describe how your child acts in school or daycare.
Cheque all that use.
___ Nervous, worried
___ Shy, withdrawn, keeps to self
___ Hyper, restless, tin't sit still
___ Gets angry easily
___ Pushy, bullies others
___ Scared, fearful
___ Relaxed, calm
___ Moody
___ Social, friendly
___ Happy
27. How are your child'south grades in school?
___ First-class ___ OK ___ Poor ___ Does not go to school
28. Virtually how much exercise does your child become every day?
___ Less than thirty minutes ___ 30 minutes to ane hour ___ Over 1 hour
29. Well-nigh how many hours of TV does your child lookout man every day?
___ Less than1 hour ___ i-iii hours ___ More than three hours
xxx. About how many hours is your child on a computer every 24-hour interval?
___ Less than 1 hr ___ 1-three hours ___ More than than three hours ___ Does not have a computer
31. Almost how many hours does your child spend exterior every solar day?
___ Less than1 hour ___ 1-iii hours ___ More than than 3 hours
32. Nigh how many hours are spent reading with your child every day?
___ Less than 15 minutes ___ 15-30 minutes ___ 30 minutes to1 hour& ___ More than 1 hour
33. Does your child wearable a helmet when riding a bike, roller blading, skate boarding, etc.?
___ Yes ___ No ___ Does not do activities like that
34. Does your kid go buckled in a machine seat or wear a seat belt when riding in a auto?
___ Yes ___ No
35. Do yous accept guns in the home? ___ Yep ___ No
If yes, are they locked upward? ___ Yeah ___ No
36. What activities is your kid involved in:
___ Riding bike
___ T-ball/baseball game
___ Dance/motility
___ Skate boarding
___ Karate
___ Video games
___ Girl Scouts/Boy Scouts
___ Soccer
___ Playing a musical instrument
___ Reading
___ Playing with friends
Other team sports ____________________________________
___ Other activity(s) ____________________________________
___ Too young to be involved in activities
37. Please list what your child typically eats and drinks in a day for:
Breakfast:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Tiffin:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Dinner:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Snacks:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Family
38. Cheque all the people that the child lives with:
___ Female parent
___ Father
___ Brothers (how many? _________________)
___ Sisters (how many? _________________)
___ Other family members (list):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___ Friends or other people (list):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___ Animals ___ Dogs (how many?_________________ ___ Cats (how many?_________________
___ Other animals):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
39. What medical bug exercise people in the child'due south family accept?
| Family Fellow member | Medical Problems |
|---|---|
| Mother: | ___ Low ___ Anxiety (nerve) problems ___ Learning disability ___ Overweight ___ High blood pressure ___ Diabetes (carbohydrate) ___ Cancer ___ Heart problems___ Other: __________________________________________ |
| Begetter: | ___ Depression ___ Feet (nervus) problems ___ Learning disability ___ Overweight ___ High claret pressure ___ Diabetes (sugar) ___ Cancer ___ Heart problems___ Other: __________________________________________ |
| Sisters: | ___ Depression ___ Anxiety (nerve) problems ___ Learning disability ___ Overweight ___ High claret force per unit area ___ Diabetes (sugar) ___ Cancer ___ Heart problems___ Other: __________________________________________ |
| Brothers: | ___ Depression ___ Anxiety (nervus) problems ___ Learning disability ___ Overweight ___ High blood pressure ___ Diabetes (saccharide) ___ Cancer ___ Eye problems___ Other: __________________________________________ |
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Source: https://www.ahrq.gov/health-literacy/improve/precautions/tool11b.html
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