Milestones Pediatrics New Patient Medical History Form

MILESTONES PEDIATRICS NEW PATIENT MEDICAL HISTORY FORM

Patient’s Last Name:Patient’s First Name:

Birthdate: ______Gender: M / FEthnicity:

Patient’s Father:Patient’s Mother:

Patient’s Brothers/Sisters (and DOB):

Doctor Who Delivered Patient:

Facility and Location ofpatient’s birth:

Birth Wt:Birth Length: Birth Head Circ:

Delivery Type: Vaginal or C-Section Vacuum or Forceps assisted:

Full Term or Preterm (total weeks):

Was Child:Breast Fed Y / N If yes, how long?

Bottle Fed Y / N Formula name(s):_

Pregnancy History

SmokingY / NMedication(s)Y / NDrugs/Alcohol Y / N

BleedingY / NHigh Blood PressureY / NPremature LaborY / N

InfectionsY / N

Other (explain)

Problems during his/her newborn period

JaundiceY / NBreathing problemsY / NInfectionsY / N

Colic Y / NFeeding problemsY / N

Other(explain)

Developmental History

At what age (approx) did your child: Sit upWalkFirst Word

Any school problems, or special help in school needed?

Family History (please indicate relationship to child)

Relationship to Child

AsthmaY / N

Anesthetic reactionY / N

Bleeding disorderY / N

Cystic FibrosisY / N

Cancer (type?)Y/ N

Diabetes (type I or II?)Y / N

Elevated cholesterol Y / N

Heart attack (age?)Y / N

Heart diseaseY / N

Early/unexplained deathY/ N

Muscular DystrophyY / N

Seasonal allergiesY / N

Sickle Cell anemiaY / N

Thyroid diseaseY/ N

Other (explain)

Child’s Allergies to Medication(s) (note reaction for each):

Allergies to Food(s) (note reaction for each):_

Please list all medication currently taken for seasonal/other allergies:

Preferred Pharmacy name: Town:

Significant Illnesses/InjuriesHospitalized?How long?

Y / N

Y / N

Y / N

Y / N

Child’s Medical History

AsthmaY / NHeart SurgeryY / N

PneumoniaY / NAnemiaY / N

Chronic CoughY / NBleeding disorderY / N

Seasonal AllergiesY / NDiabetesY / N

EczemaY / NHepatitisY / N

Frequent ‘colds’Y / NChronic ConstipationY / N

Ear infectionsY / NChronic DiarrheaY / N

Ear tubesY / NStomach PainY / N

Nose bleedsY / NSwollen painful jointsY / N

Eye SurgeryY / NChicken PoxY / N

Glasses/ContactsY / NBedwetting > age 3Y / N

Elevated CholesterolY / NSeizure DisorderY / N

Mouth SoresY / NHeadaches/MigrainesY / N

Thyroid DisorderY / NUrinary tract infectionsY / N

Heart DiseaseY / NLearning DisorderY / N

Heart MurmurY / NBehavioral DisorderY / N

ADHDY / N

Other (explain)

Child care outside the home (details):_

Tests and Immunizations (please provide a copy of child’s most recent vaccination and/or chart records)

Girls only

Ageat first menstrual period:Date of last menstrual period:_

Are periods regular? Y / NIf no, please explain:

Symptoms w/ period? Y / N If yes, please explain:_