General Medical History Form Pediatric
Name:
General Medical History Form: PEDIATRIC
Ages: Newborn through age 17
Please complete all sections that are APPROPRIATE FOR the current AGE of your child.
Date:
GHC#:
Address:
City:
State:
Zip Code:
Hm Ph: ( )
DOB:
Attends Daycare: No Yes: Name:
Child Lives With: Mother Father Step Parent/Family Other: ___________ Siblings-ages:
Name of Parent/guardian(s):
Home Phone:
Work:
Name of Parent/guardian(s):
Home Phone:
Work:
Emergency Contact 1:
Relation:
Hm:( )
Wk:( )
Emergency Contact 2:
Relation:
Hm:( )
Wk:( )
Ethnic Group: African American American Indian/Eskimo Asian/Pacific Islander Caucasian Hispanic/Latino Multi-Racial
Language Preference:
Cultural Needs and Preferences:
Child's Allergies (include date noted if known):
Health concerns to be addressed at appointment:
Child's Medications (include dose if known):
Child's Tobacco Use Status:
Current Former Never
Does anyone in the household use tobacco? Yes No Comments: _____________________
Cigarette packs/day:______ #Years:_______ Quit Date:________ Other types: Pipe Snuff Cigar Chew
Child's Alcohol use: No Yes oz/week:
Comment:
Child's Drug Use: No Yes times per week:_____ IV use Comment:
Girls: Age of first menstrual period: _________________ Date of last menstrual period: _____________________
Child's Sexual Activity: Contraception Method:
Sexually Active: Not Currently Yes No
Partners: Male Female
Condom Pill Diaphragm IUD Surgical Spermicide Implant
Rhythm Injection Sponge Insert Abstinence Other:
Child's Activities of Daily Living/Misc: Check here if there has been no change in this area since form last completed
Blood Transfusion: .................. No Caffeine Concern: ................... No Occupational Exposure: .......... No Hobby Hazards: ...................... No Sleep Concern: ....................... No Stress Concern: ...................... No
Yes Yes Yes Yes Yes Yes
Weight Concern: ........... No Follows Special Diet: .... No Practices Back Care: .... No Exercises regularly: ...... No Wears Helmet on Bike: . No Wears Seat Belt: .......... No
Yes Yes Yes Yes Yes Yes
Child's Immunization Dates: Check here if there has been no change in this area since form last completed
DPT/DTaP: _______________________________
Chicken Pox (or date of illness) ______________
Hib: _____________________________________
Tetanus Booster: ________________________
Polio: ___________________________________
Influenza: _______________________________
MMR: ___________________________________
Pneumovax ______________________________
Hepatitis B: _______________________________
Hepatitis A _______________________________
Prevnar: _________________________________
Other: __________________________________
This page entered into Epic by PCS Staff: _________________________ Date: ___________
over please
NUR03-002-04(4/08)
GENERAL MEDICAL HISTORY FORM, PEDIATRIC (Continued)
Check here if there has been no change on this page since form was last completed
Child's Long-Term/Chronic Medical Concerns
Illness
Date of Diagnosis
Child's Surgery History
Surgical Procedure
Date of Surgery
Is child adopted? yes no
Above section entered into Epic by Provider: _________________________________
Check family members who No have the following conditions History
Mother
Father
Sister
Brother
Maternal Grandmo
Maternal Grandfath
Paternal Paternal Grandmo Grandfath
Daughter
Son
Coronary Heart Disease
Congenital Heart Disease
Hyperlipidemia (high cholesterol)
Diabetes Mellitus
Depression
Mental Health Problems
High Blood Pressure
Stroke
Cancer ? Breast
Cancer ? Colon
Cancer ? Prostate
Other Cancers: Type: __________
Other
Alcoholism/Drug Abuse Asthma/Allergies Migraines Obesity Anesthesia Problems Arthritis Blood Disease/Anemia Cystic Fibrosis Genetic Disorders Stomach/Intestinal Problems Genital/Urinary problems Kidney Disease Lung Problems
Multiple Sclerosis Osteoporosis Thyroid Disorders Tuberculosis HIV/AIDS Seizure Disorder Other:
Provider OK to enter into Epic: _______________
Entered into Epic by PCS Staff: _________________
Family
History
Mother
Father
Circle One
Sibling
M F
Sibling
M F
Sibling
M F
Sibling
M F
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Circle One
Child
M F
Child
M F
Child
M F
Spouse/Other M F
If Deceased:
Alive Age at Death
Cause of Death
Child's Birth History
Birth Length________ Birth Weight_______
Birth Head Circumference________
Discharge Weight_____ Gestational Age_____ Cesarean Section yes no Apgars:
1 minute___________ 5 minutes__________ 10 minutes_________ Primary Nourishment unknown bottle-fed breast-fed Comments:
Family Hx and Peds Hx Entered into Epic by PCS Staff:_________________
................
................
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