Current Patient Check Up (2 yrs and up)


Current Patient Check Up Form (ages 3yr and up)

Date:      
Name:     D.O.B.:     
Current Problems/Concerns:     
Allergies (Medications, Vaccines, Food, others):
Current Medications:     

Child's Past Medical History

Since your child's last check up, has she or he had:
Hospitalizations? Yes No
Surgeries? Yes No
Emergency room or urgent care visits? Yes No
If yes to any of the above questions, please explain?
Does your child see the eye doctor regularly? Yes No
Does your child visit the dentist regularly? Yes No

Has your child ever been treated for any of the following?

ADHD/ADD Yes No
Allergies Yes No
Eczema Yes No
Seizures Yes No
Heart Murmur Yes No
Wheezing Yes No
Pneumonia Yes No
Ear Infections Yes No
Urinary tract infection Yes No
Acne Yes No
Serious injury or concussion Yes No
Developmental and/or speech problems Yes No
For girls only, has she started her menstrual cycle? Yes No
Other history of chronic problem?
Has your child ever been seen by a specialist? If so, please describe?

Has your child ever had:

Fainting during or after exercise, emotion or startle? Yes No
Extreme shortness of breath with exercise? Yes No
Discomfort, pain, or pressure in chest during exercise? Yes No

Family History
Do any family members have any of the following conditions?

High Blood Pressure: Mother Father Sibling Grandparent
High Cholesterol: Mother Father Sibling Grandparent
Prolonged QT: Mother Father Sibling Grandparent
Early Heart Attack (under 50 yrs. old): Mother Father Sibling Grandparent
Sudden Unexplained Death: Mother Father Sibling Grandparent
Anemia: Mother Father Sibling Grandparent
Bleeding or Clotting Disorders: Mother Father Sibling Grandparent
Allergies: Mother Father Sibling Grandparent
Autoimmune Disorder: Mother Father Sibling Grandparent
Cancer: Mother Father Sibling Grandparent
Development/Genetic Disease: Mother Father Sibling Grandparent
Diabetes: Mother Father Sibling Grandparent
Thyroid Disease: Mother Father Sibling Grandparent
Polycystic Ovarian Syndrom: Mother Father Sibling Grandparent
Ear Tubes: Mother Father Sibling Grandparent
Deafness: Mother Father Sibling Grandparent
Stomach Problems: Mother Father Sibling Grandparent
Liver Disease: Mother Father Sibling Grandparent
Celiac Disease: Mother Father Sibling Grandparent
ADD/ADHD: Mother Father Sibling Grandparent
Migraines: Mother Father Sibling Grandparent
Autism: Mother Father Sibling Grandparent
Seizures: Mother Father Sibling Grandparent
Mental Illness: Mother Father Sibling Grandparent
Drug/Alcohol Abuse: Mother Father Sibling Grandparent
Asthma: Mother Father Sibling Grandparent
Tuberculosis: Mother Father Sibling Grandparent
Kidney Problems: Mother Father Sibling Grandparent
Lazy Eye: Mother Father Sibling Grandparent
Hip Dysplasia: Mother Father Sibling Grandparent
Other: Mother Father Sibling Grandparent
Who lives in your child's home?     
If parents are not living together or if child does not live with parents, what is the child's custody status?
Is your child in:     Daycare?      School?      If so, what grade?
Do you have any concerns about your child's school performance?
Any changes to your home life? (death, divorce, social stress?)     
Do you have any special concerns today?     


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