Medical History Form 3 Years and Older
Medical History Form 3 Years and Older
This form is necessary to provide the “complete picture” of your child’s health to your provider. By gathering this
information, it allows your provider to offer the best care possible for your child(ren).
2. Please list any previous surgeries? (list month/year, hospital and surgery performed) □None
3. Please list any serious injuries or accidents? (list month/year and nature of injury/accident) □None
4. Any drug or food allergies? □Yes □No (if yes list below with reaction)
5. For girls: Has she started her menstrual periods? □Yes □No Are there problems with her periods? □Yes □No
Please CIRCLE any condition your child currently has or has had in the past:
Please explain any conditions you circled above or any other significant medical problems:
Page 1 of 3 Reproduction is allowed with permission from Complete Children’s Health, P.C. Revised 9/8/2017
(402) 465-5600
Patient Name
Family History—Check all that apply. ONLY include GENETIC family members.
(Leave blank if the child is a foster child, adopted, or if the biological parents are unknown.)
Maternal Maternal Paternal Paternal
Mom Dad Sister Brother Grandmother Grandfather Grandmother Grandfather
Cancer
Asthma/Other Lung Disease
Nasal/Other Allergies
Diabetes or Other Endocrine Problems
(before 50 years old)
High Blood Pressure
High Cholesterol
Heart Disease (before 50 years old)
Rheumatologic Disease (Arthritis,
Lupus, Thyroid Disease)
Kidney Disease
Liver Disease
Anemia
Bleeding Disorder
Developmental Delay/Disorder
Mental Illness
Epilepsy, Convulsions, or Seizures
Neurologic Disorder
ADHD/ADD
Autism
Alcohol Abuse
Drug Abuse
Hearing Problems/Deafness
Vision Impairment/Eye Disorder (not
including standard glasses or contacts)
Tuberculosis
Bed-wetting (after 10 years old)
Immune Problems, Recurrent
Infections, or HIV/AIDS
Milk and/or Soy Intolerance
Other GI Disease/Disorder
Unexplained Sudden Death (before 50
years old)
Page 2 of 3 Reproduction is allowed with permission from Complete Children’s Health, P.C. Revised 9/8/2017
(402) 465-5600
Patient Name
2. If parents are not living together or if the child does not live with parents, what is the child’s custody status?