Pediatric Health History Questionnaire

Choose an office: *

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Date:

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All questions contained in this questionnaire are strictly confidential and will become part of your medical record

Child's First Name

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Child's Last Name

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Sex:

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DOB:

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Previous or referring doctor:

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Date of last physical exam:

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PERSONAL HEALTH HISTORY

List any medical problems that other doctors have diagnosed in your child

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Surgeries

Year

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Reason

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Hospital

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Year

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Reason

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Hospital

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Year

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Reason

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Hospital

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Other hospitalizations

Year

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Reason

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Hospital

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Year

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Reason

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Hospital

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Year

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Reason

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Hospital

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Has your child ever had a blood transfusion?

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List your child’s prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Name the Drug

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Strength

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Frequency Taken

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Name the Drug

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Strength

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Frequency Taken

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Name the Drug

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Strength

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Frequency Taken

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Name the Drug

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Strength

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Frequency Taken

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Name the Drug

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Strength

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Frequency Taken

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Allergies to medications

Name the Drug

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Reaction child had

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Name the Drug

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Reaction child had

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Name the Drug

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Reaction child had

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Name the Drug

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Reaction child had

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Name the Drug

Sex

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Age

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Significant Health Problems

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Sex

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Age

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Significant Health Problems

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Sex

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Age

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Significant Health Problems

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Child’s Children (if applicable)

Sex

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Age

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Significant Health Problems

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Sex

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Age

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Significant Health Problems

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SOCIAL HEALTH

What school does your child attend?

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What grade are they in?

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Who does your child currently live with?

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How many siblings does your child have?

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Are they exposed to tobacco smoke?

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If yes, by who?

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GIRLS ONLY

Age at onset of menstruation:

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Date of last menstruation:

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Monthly periods?

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Heavy periods and/or painful periods?

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ny urinary tract, bladder, or kidney infections within the last year?

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BOYS ONLY

Any urinary tract, bladder, or kidney infections within the last year?

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Any concerns about possible hernia or abnormal nodules in groin area?

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Date

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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