PEDIATRIC MEDICAL HISTORY FORM | Merrimack Family Medicine

Present Health Concerns: __________________________________________________________________________________________

** If you are on 3 or more medications – please bring them with you to each appointment. **

PERSONAL MEDICAL HISTORY: Please indicate whether the patient has had any of the following medical problems.

Asthma

Anemia

Pneumonia

Diarrhea

Hearing Problems

Heart Disease

Ear Infections

Convulsions/Epilepsy

Constipation

Rheumatic Fever

Vision Problems

Hay Fever

Other:____________________________

_________________________________

HOSPITALIZATONS: Please list all prior hospitalizations and dates.

Reason

Date

IMMUN

IZATIONS:

Please list immunizations that the patient has received at other health care facilities and include your best estimate of the

month and year of each immunization.

Hepatitis A: _________

Hepatitis B: _________

Measles: ___________

Pneumovax: ________

Mumps: ____________

Tdap: ______________

Rubella: ____________

Varicella: ___________

MMR: ______________

Other: _____________

COMMUNICABLE DISEASES:

Has the patient ever had any of the following communicable disease(s)?

Chickenpox

Measles

Mumps

Rubella

Meningitis

Tuberculosis (TB)

PREGNANCY & BIRTH:

Is the patient yours by: □Birth □Adoption □Stepchild □Other: ________________________________________________________

Were there any medical problems during pregnancy? □ Yes □ No If yes, please explain: _______________________________________

Were there are problems during labor and delivery? □ Yes □ No If yes, please explain: _______________________________________

Were there any problems such as needing oxygen, trouble breathing, jaundice (yellowness), etc. after the patient’s birth? □ Yes □ No

If yes, please explain: ____________________________________________________________________________________________

Where was the patient born? _________________________________ Method of Delivery: □Vaginal □ Caesarean

Birth Weight/Length: ___lbs. ___oz. ___inches Was your child born prematurely? □ Yes □ No If yes how early: __________________

For Male Patients Only: Is your child circumcised? □ Yes □ No

MEDICATIONS:

Please list all prescription and non-prescription medications,

vitamins, home remedies, birth control, herbs

etc.

ALLERGIES: List all reactions to medicines, foods and other agents.

Medication Name

Dose

Frequency

Allergy

Reaction or Side Affect

PEDIATRIC MEDICAL HISTORY FORM

Patient Name: _____________________ DOB: ______/______/_______

Parent/Guardian Signature: ________________ Date: _____/______/________

Clear Form

SLEEP:

How many hours a night does the patient sleep? ______ How many naps does the patient take per day and length of naps? _________

Does the patient have any sleep problems? □ Yes □ No If yes, please explain: _______________________________________________

NUTRITION & FEEDING:

Type of feeding when the patient was a newborn: □Breastfed □Formula. If breastfed, for how long? _____________________________

Has the patient had any feeding/dietary problems or restrictions? □ Yes □ No If yes, please explain: _____________________________

_______________________________________________________________________________________________________________

Milk intake now: □ Soy Milk □ Rice Milk □ Cow’s Milk (____ %) □ other, please specify: ___________, # of ounces per day ____________

Has the patient seen a dentist? □ Yes □ No If yes, date of last visit ________. What is the water source at the house? □ City □ Well

DEVELOPMENT:

At what age did the patient: Sit Alone _____ Walk Alone _____ Say Words _____ Toilet Train (Daytime) _____

Were there any concerns about growth or progress made in such areas as rolling over, walking, riding a tricycle, dressing themself, or

feeding themself?

□ Yes □ No If yes, please explain: ________________________________________________________________

Are there any area of concerns about language or speech development? □ Yes □ No If yes, please explain: _______________________

When the patient is in the car, do they use? □ Infant Seat □ Booster Seat □ Seatbelt Only

Does the patient wear a helmet while riding a bike? □ Yes □ No

Do you have concerns about the patient’s behavior at home or in groups with other children?

□ Yes □ No

If yes, please explain: __________________________________________________________________________________________

For Female Patients Only: Age at first menstrual period _____________

SOCIAL HISTORY:

Are the patient’s parents: □ Married □ Never Married □ Separated □ Divorced If divorced, for how long? _________________________

Mother’s Employer: ________________________________ Mother’s Occupation: ___________________________________________

Father’s Employer: _________________________________ Father’s Occupation: ____________________________________________

Do any household members smoke? □ Yes □ No Is violence in the home a concern? □ Yes □ No Are there guns in the home? □ Yes □ No

Would you like to speak with the physician regarding the patient’s: □ Alcohol Use □ Tobacco Use □ Sexual Activity □ Aggressive Behavior

How many hours per day does the patient spend with the following: ___Watching TV ___On the Computer/iPad ___Playing Video Games

Do you have any concerns about lead exposure due to having an old home, or because of plumbing, and peeling paint? □ Yes □ No

Do you have smoke detectors in your home? □ Yes □ No

Who lives at home with the patient?

Name

Age

Relationship

Highest Level of Education

SCHOOL HISTORY:

Did/Does the patient attend school/preschool? □ Yes □ No Current grade in school? _______

Do you have concerns with how the patient is doing in school? □ Yes □ No

Any concerns about relationships with teachers or other students? □ Yes □ No

If more than 4 years old: does your child have a best friend? □ Yes □ No

Does your child play any sports? □ Yes □ No How many times a week? _________ How long (minutes) _________

FAMILY HISTORY: Please indicate with a check (√) who in the patient’s family has had the following conditions. In the first column please

indicate their living status. L = Living, D = Deceased, U = Unknown.

Living

Status

Asthma Diabetes

High

Blood

Pressure

Heart

Disease

Stroke Heart

Attack

Cancer

(Type)

Colon

Polyps

Depression Other

Mother

Father

Siblings

Maternal

randmother

Maternal

Grandfather

Paternal

Grandmother

Paternal

Grandfather

Other Family Members Information: (please write in)

REVIEW OF SYSTEMS: Please indicate with a check (√) any current problems your child has on the list below.

CONSTITUTIONAL

Fevers/chills/sweats

Unexplained weight loss

Fatigue/weakness

Excessive thirst or urination

CARDIOVASCULAR

Chest pain/discomfort

Leg pain with exercise

Palpitations

GASTROINTESTINAL

Abdominal pain

EYES

Change in vision

Nearsighted

Farsighted

CHEST (BREAST)

Breast lump/discharge

GENITOURINARY

Nighttime urination

Incontinence

Sexual function problems

Discharge from penis

GYNECOLOGICAL

Abnormal vaginal bleeding

Problems with conception

Problems with contraception

Vaginal discharge

Vaginal odor

Painful intercourse

Blood in bowel movement

Nausea/vomiting/diarrhea

NEUROLOGICAL

Headaches

Dizziness/light-headedness

Numbness

Memory loss

Loss of coordination

EARS/NOSE/THROAT/MOUTH

Difficulty hearing/ringing in

Hay fever/allergies

Problems with teeth/gums

RESPIRATORY

Cough/wheeze

Difficulty breathing

MUSCULO-SKELETAL

Muscle/joint pain

SKIN

Rash or mole change(s)

PSYCHIATRIC

Anxiety/stress

Problems with sleep

Depression

OTHER: _____________________________

___________________________________