Pediatrics S.C. 2010 South Arlington Heights Rd. Suite 210 Arlington Heights, IL 60056 (847) 758-2080 (847) 758-2084 Medical/Family History Questionnaire Patient Name: Date of Birth: Today's Date: Form Completed By: CHILD MEDICAL HISTORY PREGNANCY & BIRTH HISTORY Hospitalizations When? Reason Mother’s Blood Type? Blood Type? Baby’s Explain: Illnesses during pregnancy? Serious Injury: Medications during When? pregnancy? Alcohol/Drug Abuse? Reason Problems at birth? Describe: Surgery Premature? How early? When? Problems During Delivery? What Kind Allergies(list): Type of Delivery? : Did baby receive Hep B vaccine? Date of Hep B shot? Reaction: Newborn Hearing Screen? Newborn Testing? Current Medications: FAMILY HISTORY Allergies: Has anyone in the family (parents, grandparents, aunts/uncles, Has your child ever had: sisters/brothers) had: Asthma Describe Asthma Chicken Pox (year) Lung Disease Frequent Ear Infections (4times a year or more) Tuberculosis HIV/AIDS Wheezing Problems Suicide Attempts Bronchitis Heart Disease Pneumonia High Blood Pressure/Stroke TB/Lung Disease High Cholesterol Seizures/Epilepsy Blood Disorders/Sickle Cell High Blood Pressure Seizures Heart Defects/Disease Diabetes Liver Disease/Hepatitis Family Violence Diabetes Mental Illness Kidney Disease/Bladder Infections Cancer Strep Throat (3 times a year or more) Eye Disease Learning Disabilities Bone or Joint Disease Anemia Alcohol/Drug Abuse Birth Defects Bleeding Disorders/Hemophilia Hearing Loss Sexually Transmitted Diseases Speech Problems Emotional/Behavioral Diseases Kidney Disease Depression/Suicidal Thoughts Hepatitis/Liver Disease Hospitalizations/Surgeries
2010 South Arlington Heights Rd. Suite 210 Arlington Heights, IL 60056 Pediatrics S.C. (847) 758-2080 (847) 758-2084 Medical/Family History Questionnaire Patient Name: Date of Birth: Today's Date: Form Completed By: PREGNANCY & BIRTH HISTORY CHILD MEDICAL HISTORY Hospitalizations When? Mother’s Blood Type? Baby’s Blood Type? Illnesses during pregnancy? Explain: Reason Serious Injury: Medications during pregnancy? When? Alcohol/Drug Abuse? Reason Problems at birth? Describe: Surgery Premature? Problems During Delivery? How early? When? What Kind Type of Delivery? Allergies(list): : Did baby receive Hep B vaccine? Date of Hep B shot? Reaction: Newborn Hearing Screen? Newborn Testing? FAMILY HISTORY Current Medications: Allergies: Has anyone in the family (parents, grandparents, aunts/uncles, sisters/brothers) had: Has your child ever had: Describe Asthma Asthma Chicken Pox (year) Lung Disease Tuberculosis Frequent Ear Infections (4times a year or more) HIV/AIDS Suicide Attempts Wheezing Problems Bronchitis Heart Disease Pneumonia High Blood Pressure/Stroke TB/Lung Disease High Cholesterol Seizures/Epilepsy Blood Disorders/Sickle Cell High Blood Pressure Seizures Heart Defects/Disease Diabetes Liver Disease/Hepatitis Family Violence Diabetes Mental Illness Kidney Disease/Bladder Infections Cancer Eye Disease Bone or Joint Disease Alcohol/Drug Abuse Strep Throat (3 times a year or more) Learning Disabilities Anemia Birth Defects Bleeding Disorders/Hemophilia Hearing Loss Sexually Transmitted Diseases Speech Problems Emotional/Behavioral Diseases Kidney Disease Depression/Suicidal Thoughts Hepatitis/Liver Disease Hospitalizations/Surgeries
family-medical-history.docx