First Name:

Last Name:

Date of Birth:

Weight:

Preferred name:

Visit date:

Preferred Pronoun (PICK ONE):

he/him/his she/her/hers they/them/theirs decline to answer

Who referred you to our office?

Pediatrician:

What is the Main Reason for your child's visit:

How long has this problem existed:

ALLERGIES/SENSITIVITIES TO MEDICATIONS:

None

CURRENT MEDICATIONS WITH DOSAGE:

None

Preferred Pharmacy Name & Cross Streets:

Preferred Pharmacy Phone #:

Past Medical History

None

Allergies

Yes No

Anemia

Yes No

Asthma

Yes No

Bleeding disorder

Yes No

Cancer

Yes No

Depression

Yes No

Diabetes mellitus

Yes No

Ear infection

Yes No

GERD (Reflux)

Yes No

Hearing loss

Yes No

Heart disease

Yes No

Hepatitis

Yes No

Kidney disease

Yes No

Liver disease

Yes No

Pneumonia/Lung disease

Yes No

Premature birth

Yes No

Psychiatric disorder

Yes No

Seizures

Yes No

Sinus problem

Yes No

Sleep apnea

Yes No

Speech delay

Yes No

Thyroid disease

Yes No

OTHER MEDICAL PROBLEMS:

PAST SURGICAL HISTORY:

None

OTHER SURGICAL HISTORY:

FAMILY HISTORY

None

Allergies	Mother	Father	Sister	Brother	Child
Anesthesia problems	Mother	Father	Sister	Brother	Child
Asthma	Mother	Father	Sister	Brother	Child
Bleeding disorder	Mother	Father	Sister	Brother	Child
Cancer	Mother	Father	Sister	Brother	Child
Diabetes	Mother	Father	Sister	Brother	Child
Genetic disease	Mother	Father	Sister	Brother	Child
Hearing loss	Mother	Father	Sister	Brother	Child
Heart disease	Mother	Father	Sister	Brother	Child
High blood pressure	Mother	Father	Sister	Brother	Child
Kidney disease	Mother	Father	Sister	Brother	Child
Psychiatric illness	Mother	Father	Sister	Brother	Child
Stroke	Mother	Father	Sister	Brother	Child
Sudden death	Mother	Father	Sister	Brother	Child

BIRTH HISTORY

Birth Weight:

How many weeks gestation?

Pregnancy complications (list any):

NICU stay? Yes No

Newborn hearing screen results: Pass Fail Unknown

Immunizations: Up to date or delayed?

SOCIAL HISTORY

Who has legal custody? Mother Mother Father Father Other

Child lives with: Mother Mother Father Father Other

Parents are: Married Not married Partnered Separated Divorced

Does your child attend: Daycare Preschool Primary/secondary school

Number of siblings:

REVIEW OF SYMPTOMS

None

Appetite change

Low energy

Fever/chills/night sweats

Weight loss

Vision changes

Difficulty breathing

Cough

Wheezing

Nausea/vomiting

Abdominal pain

Change in bowel habits

Skin rash

Mental status changes

Weakness

Headache

Anxiety

Bleed easily

Bruise easily

FORM COMPLETED BY:

The above information is accurate to the best of my knowledge.

Form completed by:

Date:

Relationship to patient: Mother Father Other

Signature: