Pediatric Health History: Ages 6 and above
Pediatric Health History: Ages 6 and above
Medical History
Please list hospitalizations, operations, serious illnesses or accidents (with dates):
Please rate child’s general health
Excellent, Good, Fair, Poor
Please describe why you rated as above:
Please rate child’s diet:
Excellent, Good, Fair, Poor
Please describe why you rated as above:
Has the child been seen by a dentist?
If yes, how recently?
Habits
How many hours per day does the child spend doing the following activities?
Watching TV:
Playing on the computer:
Playing video games:
Exercising or playing outside:
Pediatric Health History: Ages 6 and above
Patient Name:
Social History
What is the child’s grade (level) in school?
Name of school:
Are there any concerns about school performance?
Are there any concerns about the child’s relationships with his/her peers?
Are there any concerns about the child’s relationships with his/her teachers?
Does the child have a best friend?
Does the child play a sport? Please specify:
Medications
Please list all current medications:
Medication Name Dosage Frequency Status (Active)?
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Immunizations
Are the child’s immunizations up to date? (Please bring immunization records to visit)
Pediatric Health History: Ages 6 and above
Patient Name:
Family History
For each of the following blood relatives, please describe the health status, severe illness(es), death and age at death as they apply.
Father
Mother
Sister(s)
Brother(s)
Status of child’s parents: (choose which applies)
Married, Never Married, Divorced, Single Parent
Who lives at home with the child? Please list all people and their relationships to the child.
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Is child care…
Provided at home, Provided away from home
Please specify if blood relatives have had any of the following. Choose all that apply:
Heart disease, High Blood Pressure, Kidney Disease, Allergies/Asthma, Cancer, Deafness, Diabetes, Mental/Emotional Problems, Sickle Cell, Seizures, Other hereditary conditions, Tuberculosis, HIV/Aids or Immune Problems
If other, please specify:
Pediatric Health History: Ages 6 and above
Patient Name:
Tobacco/Smoke Exposure
Patient Tobacco Use:
Circle which apply:
None, Minimal, Frequent, Daily
If so, please specify amount above
Patient’s Exposure to Smoke:
Please specify if any of the following apply:
No smokers in household, Family members smoke indoors, Family members smoke outdoors only, Caregiver smokes indoors, Caregiver smokes outdoors only, Other exposure to second hand smoke
If smokers, please specify relationship above
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Patient Name: Patient Gender: Male / Female
Patient Date of Birth: Patient’s Age:
Patient Social Security Number: Today’s Date:
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