Pediatric Health History Ages 0-11
Please complete this form about your child. You can skip the questions you don’t know the answer to. Thisinformation will help us give your child better care.
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Medical History
Has your child had an allergic reaction (bad effect) to any of the following:
I have no allergies that I know about
Medicines/drugs
Latex (like rubber gloves)
Eggs
Peanuts
Bee stings
Shellfish
Other
Please describe the medications/drugs they are allergic to
Please describe their allergies
Which medicines/drugs is your child taking? Include non-prescription, herbs, fluoride, vitamins, and supplements
Has your child had any of the following health problems or symptoms?
Allergies (seasonal, hay, fever, etc.)
Asthma
Autoimmune disorder (Lupus, Celiac disease. juvenile arthritis, etc.)
Blood disorders (Sickle Cell Anemia, clotting problems, etc.)
Cancer
Problems since birth (genetic disorders or syndromes, birth defect)
Diabetes
Heart problems (including a murmur or high blood pressure)
High cholesterol
Chest pain, difficulty breathing, wheezing, or coughing with exercise
Broken bones
Period/menstrual problems
Cavities or tooth pain/injuries
Dizziness, fainting, or heat-related illness
Headaches/migraines
Vision, hearing, or speech problems
Head injury or concussion
Seizures
Missing or damaged organs (eye, kidney, testicle)
Urinary, kidney, or testicle problems
Eating disorders (throwing up after eating, not eating enough, or eating too much)
Learning disability or special education needs (IEP or 504 plan)
Mental health condition (ADHD, anxiety, depression, etc.)
Autism Spectrum Disorder
Stomach problems
Developmental delay
Down syndrome
Other
Which type of cancer have they had?
Which bones have they broken?
What stomach problems have they had?
Have they had any surgeries, major injuries, or been in the hospital overnight?
Yes
No
What surgeries or injuries have they had/why were they in the hospital overnight?
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Oral Health
Do they go to the dentist regularly, 1x or more every year?
Yes
No
When was your last visit to the dentist?
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Birth History
What city and country was your child born in?
Was your child born more than one month early?
Yes
No
I don't know
Were there problems with the pregnancy or birth?
Yes
No
I don't know
What were the problems with the pregnancy or birth?
Did the birthing parent smoke, use drugs, or drink alcohol during the pregnancy, including before they knew they were pregnant?
Yes
No
I don't know
Which substances did the birthing parent use during pregnancy?
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Family Medical History
Medical problems can run in families. Please check the boxes below to tell us about any health problems in your child's family.
Is their biological mother alive?
Yes
No
I don't know
What health problems does their biological mother have?
Diabetes
Kidney problems
Heart problems
Stroke/blood clots
Alcohol/drug abuse
High blood pressure
Mental health conditions (depression, anxiety, ADHD, bipolar disorder, etc.)
Cancer
Other
Which type of cancer?
Is their biological father alive?
Yes
No
I don't know
What health problems does their biological father have?
Diabetes
Kidney problems
Heart problems
Stroke/blood clots
Alcohol/drug abuse
High blood pressure
Mental health conditions (depression, anxiety, ADHD, bipolar disorder, etc.)
Cancer
Other
Which type of cancer?
Do they have biological siblings?
Yes
No
I don't know
What health problems do their biological siblings have?
Diabetes
Kidney problems
Heart problems
Stroke/blood clots
Alcohol/drug abuse
High blood pressure
Mental health conditions (depression, anxiety, ADHD, bipolar disorder, etc.)
Cancer
Other
Which type of cancer?
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Social and Environmental History
Yes
No
Does anyone in the family smoke?
Is your child in school?
Are there any pets at home?
Have you recently traveled outside of the area?
Has there been a divorce or separation in your family?
Has there been any CPS involvement in your family?
Is your child in foster care or a group home?
Are any parents incarcerated?
Has your child or another child in the home been incarcerated?
Often true
Sometimes true
Never true
Don't know
Within the last 12 months I worried whether food would run out before I got money to buy more
Within the last 12 months the food we bought just didn't last and we didn't have money to get more
What is your housing situation today?
We have permanent housing
We do not have permanent housing, we live with others
We do not have permanent housing, we live on the street/camp/car
We do not have permanent housing, we live in a shelter
We do not have permanent housing, we live in transitional housing
Is there anything else we should know?
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