Medical History Form Updated

MEDICAL HISTORY FORM

Patient’s First Name

Patient’s Last Name

Pediatrician’s Phone #

Pediatrician’s Name:

When was the child’s last general check-up?

Is your child being treated by a physician at this time?

Yes No

If yes, why?

Has your child ever been a patient in the hospital?

Yes No

If yes, why?

Is your child taking any medications at this time?

Yes No

If yes, what?

Has child had any history with the following:

Allergic to Latex

Yes No

If yes, please explain.

Allergic to Antibiotic/Other

Yes No

If yes, please explain.

ADD

Yes No

If yes, please explain.

ADHD

Yes No

If yes, please explain.

Autism

Yes No

If yes, please explain.

AIDS/HIV

Yes No

If yes, please explain.

Anemia

Yes No

If yes, please explain.

Asthma

Yes No

If yes, please explain.

Bladder Problem

Yes No

If yes, please explain.

Cancer

Yes No

If yes, please explain.

Cerebral Palsy

Yes No

If yes, please explain.

Chicken Pox

Yes No

If yes, please explain.

Convulsions

Yes No

If yes, please explain.

Developmentally Delayed

Yes No

If yes, please explain.

Diabetes

Yes No

If yes, please explain.

Epilepsy

Yes No

If yes, please explain.

Hearing Problem

Yes No

If yes, please explain.

Heart Murmur

Yes No

If yes, please explain.

Hepatitis

Yes No

If yes, please explain.

Kidney Disease

Yes No

If yes, please explain.

Liver Disease

Yes No

If yes, please explain.

Measles

Yes No

If yes, please explain.

Mumps

Yes No

If yes, please explain.

Rheumatic Fever

Yes No

If yes, please explain.

Sinus Problem

Yes No

If yes, please explain.

Thyroid Problem

Yes No

If yes, please explain.

Any other conditions we should be aware of?

In case of Emergency, who should we contact other than you?

Name

Relationship

Phone

Date this form was completed