Pediatric Health History: Ages 0-1



Pediatric Health History: Ages 0-1

Pregnancy and Birth

Where was the child born? Please list the state and hospital.

Please indicate if mother had any of the following problems during pregnancy:

Bleeding, Gestational Diabetes, Hepatitis B, Herpes, High Blood Pressure, Illnesses/Infections, Preterm Labor, Spotting, Threatened Miscarriage, Toxemia, Other

If illnesses or infections please specify:

If other, please specify:

Were any medications taken during pregnancy? Please choose all that apply.

Prenatal Vitamins, Other

If other, please specify:

What was the length of pregnancy (in weeks)?

What was the length of labor (in hours)?

What was the method of delivery?

Vaginal , C-Section

Please list the child’s Apgar scores, if known.

Did child breathe immediately after birth?

Birth Weight:

Birth Length:

Pediatric Health History: Ages 0-1

Patient Name:

Did mother or child experience any of the following complications of delivery? Please check all that apply:

Prolonged Labor, Needed Oxygen, Jaundice, Phototherapy, Needed Resuscitation, ICU Stay, Other

If ICU Stay, why?

If other, please specify:

Medical History

Please list hospitalizations, operations or accidents (with dates):

Has the child experienced any of the following medical illnesses/problems/infections? Please choose all that apply:

Allergies, Asthma, Chicken Pox, Diabetes, Developmental Delays, Ear Infections, Eczema, Head Injuries, Meningitis, RSV, Seizures, Tuberculosis, Urinary Tract Infections, Whooping Cough (Pertussis), Other

If other, please specify:

At what age did the child reach the following milestones? If the child has not reached the milestone, please mark “N/A”

Smiles

Giggles

Rolls Over

Sits

Crawls

Pulls to Stand

Imitates Speech Sounds

Nutrition and Sleep

Is/was the child breast fed?

Until what age?

Pediatric Health History: Ages 0-1

Patient Name:

At what age did the child start eating solids (if applicable)?

Has the child had feeding problems?

If yes, please specify:

How many hours does the child sleep per night?

Does the child have any sleep problems?

Medications

Please list all current medications:

Medication Name Dosage Frequency Status (Active)?

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

Immunizations

Are the child’s immunizations up to date? (Please bring immunization records to visit)

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)

Pediatric Health History: Ages 0-1

Patient Name:

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.

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

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 condition, Tuberculosis, HIV/Aids or Immune Problems

If other, please specify:

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

-----------------------

Patient Name: Patient Gender: Male / Female

Patient Date of Birth: Patient’s Age:

Patient Social Security Number: Today’s Date:

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download