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Child's Name
_________________________________________________________
_________________________________________________________
_________________________________________________________
Today's Date: ___________________________________
Date of Birth: ___________________________________
Child's Address
__________________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________________
Filling out this form
- Answering these questions will help your doctor understand your child's health and how best to treat your child.
- If you need help filling out this form:
- Bring this form with you to your appointment and a nurse will help you.
OR
- Call the clinic at [555-1212 ext. 123] before your appointment and someone can help you over the phone.
- Bring this form with you to your appointment and a nurse will help you.
Bring to your appointment:
We look forward to working with you!
General Information
What is the child's sex? ___ Female ___ Male
Child's Date of Birth______________________ current age ___________________________________
Is your child adopted? ___ No ___ Yes If yes, at what age? ___________________________________
Who is filling out this form?
___ Mother
___ Father
___ Other guardian (please explain relationship to child): ________________________
___ Other (please explain): ______________________________________________________________________
The child's parents are:
___ Single ___ Married ___ Divorced ___ Separated but not divorced
___ Widowed ___ Living together but not married ___ Unknown
| Name: ________________________ | Name: ________________________ |
| Relation to child: ___ Mother ___ Father ___ Other: ________________________ | Relation to child: ___ Mother ___ Father ___ Other: ________________________ |
| Address: ___ Same as child's Street address: ____________________ ________________________ City: ________________________ State: _____________________ Zip: ____________________ | Address: ___ Same as child's Street address: ____________________ ________________________ City: ________________________ State: _____________________ Zip: ____________________ |
| Home Phone: | Home Phone: |
| Cell Phone: | Cell Phone: |
| Work Phone: | Work Phone: |
Today's Health Problems
1. List your child's main health problems (or reasons for visiting the clinic).
___ Routine checkup
___ Immunizations (shots)
___ A health problem (please specify): __________________________________________________________________________________________________)
___ Switching doctors (last doctor): __________________________________________________________________________________________________)
2. How well do you feel your child acts or behaves?
___ Poor ___ Fair ___ Good ___ Very Good ___ Excellent
Medical History
3. Has your child ever been a patient in a hospital (other than a few days after birth)?
___ No (If no, go to question #4.)
___ Yes (If yes, explain why and when below.)
| Example: Bike accident | 5 years old |
4. Is your child taking any prescription medicines?
___ Yes—Please list the child's medicines below or ___ I brought my child's medicines.
___ No. My child does not take any prescription medicines. (If no, go to question #5.)
| Example: Dexadrine | 10 mg | 1 morning ___ noon ___ dinner 1 bed |
| ___ morning ___ noon ___ dinner ___ bed | ||
| ___ morning ___ noon ___ dinner ___ bed | ||
| ___ morning ___ noon ___ dinner ___ bed | ||
| ___ morning ___ noon ___ dinner ___ bed | ||
| ___ morning ___ noon ___ dinner ___ bed | ||
| ___ morning ___ noon ___ dinner ___ bed |
(Please use the back of this form if you have more prescription medicines.)
5. What over-the-counter medicines, does your child take regularly?
___ Vitamins
___ Herbal medicine (please list) ________________________________________________________________________
___ Other (please list) __________________________________________________________________________________
___ None, my child does not take any over-the-counter medicines regularly.
6. Does your child have any allergic reaction (bad effects) from any of the following? (Check all that apply.)
___ Outside or Indoor allergies (for example: grass, pollen, cats …)
___ Food Allergies (for example: peanuts, milk, wheat …)
___ Medicine or shots (immunization). (Please list below.)
___ No, my child has no allergies that I know of.
| Example: Amoxicillin | Diarrhea (runny poop) |
7. Has your child had any of the following diseases?
| Measles | ___ Yes | ___ No | ___ Don't Know |
| Mumps | ___ Yes | ___ No | ___ Don't Know |
| Chicken Pox | ___ Yes | ___ No | ___ Don't Know |
| Whooping Cough | ___ Yes | ___ No | ___ Don't Know |
| Rubella | ___ Yes | ___ No | ___ Don't Know |
| Rheumatic Fever | ___ Yes | ___ No | ___ Don't Know |
| Scarlet Fever | ___ Yes | ___ No | ___ Don't Know |
8. Please check any of the following medical problems that your child has ever had.
| Has your child ever had: | |
| Ear infections | ___ Yes ___ No |
| Nose problems (sinus infections, nose bleeds) | ___ Yes ___ No |
| Eye problems (blurry vision, need to wear glasses) | ___ Yes ___ No |
| Hearing problems | ___ Yes ___ No |
| Mouth or throat problems (Strep throat, swallowing problems) | ___ Yes ___ No |
| Diarrhea (having frequent and runny bowel movements/poop) | ___ Yes ___ No |
| Constipation (problems having a bowel movement /poop) | ___ Yes ___ No |
| Problems peeing (bed wetting, pain when peeing) | ___ Yes ___ No |
| Back problems (crooked back, back pain) | ___ Yes ___ No |
| Growing pains (bone or body pains due to growing) | ___ Yes ___ No |
| Muscle and bone problems (weak muscles, pain in joints) | ___ Yes ___ No |
| Skin problems (acne, flaking skin, rashes, hives) | ___ Yes ___ No |
| Seizures (shaking fits) | ___ Yes ___ No |
| ADD/ADHD (problems paying attention, sitting still) | ___ Yes ___ No |
| Sleeping problems (falling or staying asleep) | ___ Yes ___ No |
| Breathing problems (cough, asthma) | ___ Yes ___ No |
| Warts | ___ Yes ___ No |
| Jaundice (yellow skin) | ___ Yes ___ No |
Shots
9. Has your child received immunizations (shots) in the past?
___ No (If no, go to question #10.)
___ Yes
If yes, have you given this office a copy of the immunization (shots) records?
___ Yes (If no, go to question #10.)
___ No
If not, please give us the name of the doctors' offices or clinics where your child has received these shots so we can get the records.
Doctor's office/clinic name: ____________________________________________________________
Doctor's office/clinic phone number: ____________________________________________________________
About Mom When Pregnant
The following questions are about the mother of the child during pregnancy and birth.
If you do not know about the pregnancy of the mother, check here ___ and go to #17.
10. What was the general health of the mother during pregnancy?
___ Excellent ___ Good ___ Fair ___ Poor ___ Unknown
11. Were any of the following used during pregnancy?
___ Cigarettes
___ Alcohol
___ Illegal drugs (which ones? ___________________________________________)
___ Prescription drugs (which ones? ______________________________________)
___ None of the above
12. Did the mother have any of the following conditions or problems during pregnancy?
___ Preeclampsia (high blood pressure)
___ Diabetes (sugar)
___ Emotional stress
___ Injury or serious illness
___ Unexpected bleeding or spotting
___ Other ____________________________________________________________
13. Was the birth:
___ On the due date
___ Before the due date (by how much ____________________________________________________________)
___ After the due date (by how much ____________________________________________________________
14. Was the birth: ___ Vaginal ___ C-Section (surgical cut in the tummy?)
15. Were any of the following used?
___ Pain medicine during birth (epidural)
___ Tool to help pull baby out (forceps or vacuum)
___ None
16. Were there any problems during the birth? ___ Yes ___ No
If yes, please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
About the Child As a Baby
17. Was/is the child breastfed? ___ Yes ___ No
If yes, how long ____________________________________________________________
18. In the first 2 months after birth, did the child have:
___ Jaundice (yellow skin)
___ Colic (upset stomach, crying)
___ Breathing problems
___ Other ____________________________________
___ None of the above
19. At what age did the child begin to crawl? ____________________________________
20. At what age did the child begin to sit up? ____________________________________
21. At what age did the child begin to walk? ____________________________________
22. At what age did the child get his/her first tooth? ____________________________________
23. At what age did the child began to say words (mama, dada)? ____________________________________
24. How would you rate your child's health in his or her first year of life?
___ Excellent ___ Very Good ___ Good ___ Fair ___ Poor ___ Unknown
In School and At Home
25. Does the child go to school or daycare? ___ Yes ___ No
If yes, what is its name?________________________________________________________________________
26. If your child goes to school or daycare, describe how your child acts in school or daycare.
Check all that apply.
___ Nervous, worried
___ Shy, withdrawn, keeps to self
___ Hyper, restless, can't sit still
___ Gets angry easily
___ Pushy, bullies others
___ Scared, fearful
___ Relaxed, calm
___ Moody
___ Social, friendly
___ Happy
27. How are your child's grades in school?
___ Excellent ___ OK ___ Poor ___ Does not go to school
28. About how much exercise does your child get every day?
___ Less than 30 minutes ___ 30 minutes to 1 hour ___ Over 1 hour
29. About how many hours of TV does your child watch every day?
___ Less than1 hour ___ 1-3 hours ___ More than 3 hours
30. About how many hours is your child on a computer every day?
___ Less than 1 hour ___ 1-3 hours ___ More than 3 hours ___ Does not have a computer
31. About how many hours does your child spend outside every day?
___ Less than1 hour ___ 1-3 hours ___ More than 3 hours
32. About how many hours are spent reading with your child every day?
___ Less than 15 minutes ___ 15-30 minutes ___ 30 minutes to1 hour& ___ More than 1 hour
33. Does your child wear a helmet when riding a bike, roller blading, skate boarding, etc.?
___ Yes ___ No ___ Does not do activities like that
34. Does your child get buckled in a car seat or wear a seat belt when riding in a car?
___ Yes ___ No
35. Do you have guns in the home? ___ Yes ___ No
If yes, are they locked up? ___ Yes ___ No
36. What activities is your child involved in:
___ Riding bike
___ T-ball/baseball
___ Dance/movement
___ Skate boarding
___ Karate
___ Video games
___ Girl Scouts/Boy Scouts
___ Soccer
___ Playing a musical instrument
___ Reading
___ Playing with friends
Other team sports ____________________________________
___ Other activity(s) ____________________________________
___ Too young to be involved in activities
37. Please list what your child typically eats and drinks in a day for:
Breakfast:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Lunch:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Dinner:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Snacks:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Family
38. Check all the people that the child lives with:
___ Mother
___ Father
___ Brothers (how many? _________________)
___ Sisters (how many? _________________)
___ Other family members (list):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___ Friends or other people (list):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___ Animals ___ Dogs (how many?_________________ ___ Cats (how many?_________________
___ Other animals):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
39. What medical problems do people in the child's family have?
| Mother: | ___ Depression ___ Anxiety (nerve) problems ___ Learning disability ___ Overweight ___ High blood pressure ___ Diabetes (sugar) ___ Cancer ___ Heart problems___ Other: __________________________________________ |
| Father: | ___ Depression ___ Anxiety (nerve) problems ___ Learning disability ___ Overweight ___ High blood pressure ___ Diabetes (sugar) ___ Cancer ___ Heart problems___ Other: __________________________________________ |
| Sisters: | ___ Depression ___ Anxiety (nerve) problems ___ Learning disability ___ Overweight ___ High blood pressure ___ Diabetes (sugar) ___ Cancer ___ Heart problems___ Other: __________________________________________ |
| Brothers: | ___ Depression ___ Anxiety (nerve) problems ___ Learning disability ___ Overweight ___ High blood pressure ___ Diabetes (sugar) ___ Cancer ___ Heart problems___ Other: __________________________________________ |
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