Community Memorial Health Systems (Pediatric History)

Pediatric Medical History Historia Médica Pediátrica

If not listed here: Please Discuss with your Physician

Social History

Child lives with (mark all that apply):

stepmother

other relative

mother only

stepfather

foster parent

father only

both parents

grandparents

Number of siblings (brothers and sisters):

0

1

2

3

4

5

6

7

8 or more

If applicable, how is the patient performing in school?

excelling

satisfactorily

having difficulty

Any concerns about lead exposure?

yes

no

Are there any guns in the home?

yes

no

Are there working smoke detectors in the home?

yes

no

Is there any violent behavior in the family?

yes

no

Does anyone in the household smoke?

yes

no

Childcare situation:

parents

relative

daycare

babysitter/nanny

Mark any concerns about your child:

alcohol use

tobacco use

discipline / behavior problems

sexual activity

aggressive behavior

If not listed here: Please Discuss with your Physician

Birth History

Patient was born:

on time

premature

Delivery was:

vaginal delivery

Cesarean section

Please indicate any maternal health problems during this pregnancy:

preterm labor

high blood pressure

diabetes

drug use

major abdominal injury

preeclampsia

alcohol use

tobacco use

Did baby have any problems after birth?

yes

no

Is the child yours by:

birth

adoption

stepchild

other

If not listed here: Please Discuss with your Physician

Nutrition and Feeding

Feeding style:

breast

bottle

both

Number of months:

1-5

6-10

11-15

16-20

21-25

26-30

31-35

36+

Milk intake now:

cow's milk

1% fat

whole

nonfat

2% fat

soy/rice milk

Average ounces of milk per day (8 ounces = 1 cup)

None

1-8

9-16

17-24

25-32

33 or more

If not listed here: Please Discuss with your Physician

Sleep

If not listed here: Please Discuss with your Physician

Allergies

No known drug allergies

Penicillin

Sulfa Drugs

Iodine

Latex

Peanut

Dairy

Seafood

Bee Sting

If not listed here: Please Discuss with your Physician

Medication

Not actively taking any medications - prescription or otherwise

If not listed here: Please Discuss with your Physician

Immunizations

child has had no immunizations

has had some

all immunizations are up to date

Please bring your child's immunization records to his/her appointment

If not listed here: Please Discuss with your Physician

Your Medical History

Please indicate if the PATIENT has a history of the following.

Select all that apply. If none, select "No medical history."

No medical history

If not listed here: Please Discuss with your Physician

Surgical History

Patient has had no surgeries.

Adenoids Removed

Appendix Removed

Ear Tube(s) Inserted

Hernia Repair

Heart Surgery

Pyloric Stenosis

Tonsils Removed

If not listed here: Please Discuss with your Physician

Family Medical History

Please indicate which of the PATIENT'S family members have had these illnesses:

Family history unknown

Adopted

None

ADD / ADHD

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Alcoholism

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Anxiety

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Asthma

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Bipolar Disorder

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Cancer

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Depression

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Diabetes (Juvenile Onset)

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Diabetes (Adult Onset)

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Coronary Artery Disease

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

High Blood Pressure

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Migraines

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Rheumatoid Arthritis

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Seizures / Convulsions

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Sickle Cell Anemia

Father

Mother

Brother

Sister

Grandmother Mother’s side

Grandfather Mother’s side

Grandmother Father’s side

Grandfather Father’s side

Patient Information

Información del paciente

Pediatric Medical History Historia Médica Pediátrica

Social History

Antecedentes Sociales

Birth History

Antecedentes de Nacimiento

Development

Desarrollo

Nutrition and Feeding

Nutrición y Alimentación

Sleep

Sueño

Allergies

Alergias

Medication

Medicamentos

Immunizations

Vacunas

Your Medical History

Sus Antecedentes Médicos

Surgical History

Antecedentes Quirúrgicos

Family Medical History

Antecedentes Médicos de la Familia