Comprehensive Pediatric Medical History Form

Patient Information

• Full Name: _________________ Date of Birth: _________________
• Age: _____ Sex: _____ Primary Language: _________________
• Parent/Guardian Names: _________________
• Contact Numbers: (Home) _________ (Cell) _________ (Work) _________

Birth History

• Birth Weight: _______ Length: _______ Gestational Age: _______
• Type of Delivery: □ Vaginal □ C-Section
• Complications during pregnancy/delivery: _________________
• APGAR Scores (if known): 1 min _____ 5 min _____

Growth & Development

• Age when child: Sat alone _____ Walked _____ First words _____
• Current Height: _____ Weight: _____ BMI: _____
• Development concerns: _________________

Immunization History

□ Up to date (attach records) □ Delayed schedule □ Religious/Personal exemption

Medical History

Past Medical Conditions

□ Asthma □ Seizures □ Allergies □ Heart Problems □ Other: _________________

Medications

• Current medications: _________________
• Allergies to medications: _________________

Family History

Check if any blood relatives have had: □ Diabetes □ Heart Disease □ Mental Health Conditions □ Cancer □ Genetic Disorders □ Autoimmune Conditions

Social History

• School/Daycare: _________________
• Siblings (ages): _________________
• Pets in home: _________________
• Smoking in home: □ Yes □ No

Review of Systems

Please check any current concerns: □ Feeding/Dietary □ Sleep □ Behavior □ Vision □ Hearing □ Other concerns: _________________

Parent/Guardian Signature: _________________ Date: _________________ Provider Review: _________________ Date: _________________