Form Completed by Sex Child's Medical History Has your child ever had ... Allergies?
Asthma/Wheezing Pneumonia Chicken Pox Frequent Ear Infections Vision Problems Hearing Problems Skin Problems/Eczema/Hives Seasonal Allergies Seizures / Epilepsy High Blood Pressure Heart Defects / Disease Liver Disease Diabetes Kidney Disease Bladder Infections Physical or Learning Disabilities Bleeding Disorders/Hemophilia Sexually Transmitted Infections Emotional/Behavior Problems Depression/Suicidal Thoughts Hospitalizations/Surgeries Physical/Sexual/Emotional Abuse Bone or Joint Injuries Dental Problems Obesity/Overweight Eating Disorders Sleep Problems Attention Deficit Disorder Lead Poisoning Vaccines Up-To-Date Family Medical History Has any parent(P), grandparent(GP), aunt(A), uncle(U), sister(S) or brother(B) had... Severe Food Allergies Asthma/Wheezing TB/Lung Disease Cystic Fibrosis Genetic Disorders Migraines Heart Disease Sudden Cardiac Death High Blood Pressure Stroke High Cholesterol Blood Disorders Sickle Cell Anemia Thalassemia Clotting Disorders Diabetes Seizures Mental Illness Depression Suicide Attempts Cancer Breast Cancer Cervical Cancer Colorectal Cancer Other type of Cancer Birth Defects Hearing Loss Speech Problems Kidney Disease Alcohol/Drug Abuse Hepatitis/Liver Disease Irritable Bowel Syndrome Thyroid Disease Crohn Disease Ulcerative Colitis Attention Deficit Disorder Mental Retardation Family Violence Has any family member ever had an unexplained, unexpected death before age 50? Pregnancy and Birth History Adopted Prenatal Care Illnesses during pregnancy: Medications during pregnancy Alcohol/Drug Abuse Tobacco use Problems at birth Mom: Miscarriage Baby
Please select all that apply
Type of Delivery Newborn Hearing Screening Did baby receive Hep B vaccine? Psychosocial History Is child in daycare Are parents divorced or separated Tobacco use in household Sleep Problems Medication Allergies (Please List) Severe Food Allergies (Please List) Feeding & Digestion Breast fed Severe colic in first 3 months Feeding problems Good appetite Vitamins or other supplement Eats balanced diet Constipation problems Food allergies/issues Medical History Broken Bones Serious accidents Surgeries Hospitalizations ER visits / Urgent Care