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Robert L. Craig School, Moonachie NJHealth HistoryName ____________________ DOB_______________ Age_____ Sex: M F Grade________Past History (List with Date and age)1. Hospitalization _____________________________________________________________ _________________________________________________________________________2. Illness_____________________________________________________________________ __________________________________________________________________________3. Injuries____________________________________________________________________ __________________________________________________________________________4. Medications________________________________________________________________ ___________________________________________________________________________5. Allergies____________________________________________________________________ ___________________________________________________________________________6. Last Health Care Visit________________ Name of Provider___________________________7. Dental Care/Date of last visit_______________ Name of Provider______________________PRENATAL HISTORY1. Maternal Age _________ Length of Pregnancy__________ Prenatal Care: Yes. No2. Habits: Smoking cigarettes _______ Alcohol consumption _________ Drugs________3. High risk factors (circle) Infections, bleeding, high blood pressure, anemia, fever, trauma, Medications, weight gain, chronic disease, hospitalization, other ____________________4. Labor & Delivery: Length _________ Type__________ Birth weight___________________ Problems__________________________________________________________________5. Neonatal: Problems (circle). Breathing infections, RH factor, jaundice, transfusions, bleeding, Congenital anomaly, feeding difficulty, other ______________________________________DEVELOPMENT1. Sat alone5. Combined words2. Crawled6. Toilet trained3. Stood7. Other4. Walked aloneFamily HistoryBiological Mother ‘s Age:_________ Health__________________________________________Biological Father’s Age: ___________ Health__________________________________________Siblings: Name Sex Age Health1.________________________________________________________________________2.________________________________________________________________________3.________________________________________________________________________4.________________________________________________________________________Maternal Grandparents:1. Grandmother’s Age ___________ Health____________________________________2. Grandfather’s Age____________Health____________________________________Paternal Grandparents:1. Grandmother’s Age ____________Health____________________________________2. Grandfather’s Age _____________Health____________________________________Familial diseases: (circle) Heart Disease, stroke, hypertension, diabetes, asthma, allergy, anemia, arthritis, sickle cell disease, cancer, epilepsy, cataracts, glaucoma, kidney disease, TB, mental problems, mental retardation, learning problems, other ________________________________________Parents signature_______________________________________________________________ ................
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