New Patient History Form


New Patient History Form

Patient's Name
Child's Birthdate
Age
Sex
Female Male
Forms completed by

Household

Please list all those living in the child's home.

NameRelationshipBirthdate

Birth History


Was the delivery vaginal or cesarean?

If cesarean, why?

What was the baby's birth weight?

Did the baby have any problems right after birth? (infection, low blood sugar, breathing problems, time in the NICU)

If Yes, please explain:

Did the baby go home with mother from hospital?

If No, please explain:

Did the baby pass the hearing screen completed at the hospital?

 

Was the baby born at term?

If No, how many weeks?

Did baby have metabolic screening done?(PKU testing)?

Any abnormalities found?

If Yes, please explain:

Did mother have any illness or problem with pregnancy?

If Yes, please explain:

During pregnancy did mother smoke?

 

During pregnancy did mother use drugs or medication?

If Yes, please explain:

During pregnancy did mother drink alcohol?

 

Childs Past Medical History

Explain:
Has your child had any surgery?
Has your child ever been hospitalized?
Is your child allergic to any medications?
Is your child allergic to any foods?
Has your child been seen by a specialist? Who & When?
Does your child have or has he/she ever had any of the following?
Frequent Ear Infection
Problems with ears or hearing
Asthma / wheezing
Bronchitis
Pneumonia
Nasal allergies
Any heart problem or heart murmur
Anemia
Bleeding Disorder
Blood transfusion
Frequent abdominal pain
Constipation requiring doctors visits
Bladder or kidney infection
Bed-wetting (after 5 years of age)
Any chronic or recurrent skin problems (Acne, exzema, etc)

Seizures


Thyroid or other endocrine problems
Diabetes
Use of alcohol or drugs
Celiac disease
Concussion / Head Injury
Any other significant problems

For Girls Only

Explain:
Has she started a menstrual cycle?
Are there problems with her periods?

Current Medication

Name of MedicationDosage:

Academic History

If your child is in school:

How is his/her behavior in school?
Has he/she failed or repeated a grade in school?
How is he/she doing in academic subjects?
Does your child have an IEP?

Developmental History

Explain
Do you have any concerns about your child's development?
Has your child had speech therapy?
Has your child had physical therapy?
Has your child had occupational therapy?

Family History

Have any family members had the following:

WhoComments
Deafness
Allergies
Asthma
Tuberculosis
Heart Disease
High blood pressure
High Cholesterol
Anemia
Bleeding Disorder
Liver Disease
Kidney Disease
Diabetes
Cancer
Bed-wetting
Epilepsy or convulsion
Alcohol abuse
Drug abuse
Mental illness
Mental retardation
Immune problems
Celiac disease
Prolonged QT Syndrome
Died suddenly under age 50
Autism
HIV/AIDS

Social History

Does any of your family members or caregiver smoke?
Is your child in daycare?
Are there any guns in the home
Are there any pets in the home?
If yes, what type?


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