Medical History Form 3 Years and Older

Medical History Form
Patient’s First/Last Name: __________________________ Birthdate _____________________
Age ___________ Date ____________
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).
Patient’s Past Medical History—Please Print

1. Please list any previous hospitalizations? (list month/year, hospital and reason for hospitalization) □None
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:
Chicken pox Blood transfusion

If Yes When? Frequent abdominal pain or GERD
Eye conditions/corrective lenses Constipation requiring doctor visits
Frequent ear or sinus infections Bladder, kidney infection or other urologic problem
Problems with ears or hearing Bed-wetting (after 5 years old)
Frequent pharyngitis or tonsillitis Thyroid or other endocrine problem
Allergic rhinitis or other allergy Diabetes
Indoor allergens: Chronic or recurrent skin problem (acne, eczema, etc)
Outdoor allergens: Frequent headaches
Asthma Seizures or other neurologic problems
Frequent bronchitis, bronchiolitis, or pneumonia Developmental delay or disorder
Recurrent Croup Behavior disorder (ADHD, ODD, other)
Other chronic/serious lung disease Mental health concerns or disorder
Tuberculosis or positive TB test Emotional problems or suicide attempts
High blood pressure Use of alcohol or drugs
High cholesterol Cancer
Heart murmur HIV/AIDS
Congenital/acquired heart defect Sexually transmitted infection
Anemia or bleeding problem Orthopedic problem
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)
Additional Pertinent Conditions

Explain
(402) 465-5600
Patient Name
Developmental History—Please Print

1. Is there any significant medical history pertaining to your child’s birth or development? □Yes □No
(if yes describe) _________________________________________________________________________________
2. Is child in school? □Yes □No

3. Does your child have any difficulties in academics? □Yes □No
4. Is he/she in special resource class? □Yes □No
5. Has he/she failed or repeated a grade? □Yes □No
6. Has he/she been diagnosed with a learning disorder? □Yes □No
Social History—Please Print
List the name of those LIVING IN THE HOUSEHOLD- include any

parents, siblings , any extended family, step-family, grandparents, Date of Birth Relationship to Child
others
1. Parents’ Marital Status: □Married □Divorced □Separated □Never Married □Other
2. If parents are not living together or if the child does not live with parents, what is the child’s custody status?
3. What is the visitation status of any non-custodial parent(s)?
4. Parent’s Name/Occupation: ____________________________________________

Parent’s Name/Occupation: _____________________________________________
5. Daytime Status: □Home □Daycare □School

6. Does anyone in the household smoke? □Yes □No
7. Does anyone at daycare smoke? □Yes □No □Not applicable
8. Are there pets in the home? □Yes □No
9. Are there pets in the daycare? □Yes □No □Not applicable
10. Are there firearms in the home? □Yes □No
11. Are the guns locked and kept separate from ammunition? □Yes □No □Not applicable
(402) 465-5600

Medical History Form 3 Years and Older

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Medical History Form 3 Years and Older

Uploaded by

Copyright:

Available Formats

Medical History Form

Patient’s First/Last Name: ______ Birthdate _

Age _ Date __

Patient’s Past Medical History—Please Print

Chicken pox Blood transfusion

Additional Pertinent Conditions

Developmental History—Please Print

(if yes describe) _________________________________________________________________________________

2. Is child in school? □Yes □No

Social History—Please Print

List the name of those LIVING IN THE HOUSEHOLD- include any

1. Parents’ Marital Status: □Married □Divorced □Separated □Never Married □Other

3. What is the visitation status of any non-custodial parent(s)?

4. Parent’s Name/Occupation: ____________________________________________

5. Daytime Status: □Home □Daycare □School

You might also like