PEDIATRIC HEALTH HISTORY FORM - azfamilycare

1 Name of Person Completing FormDATER elationship to PatientSEXRACESOCIAL SECURITY NUMBERDATE OF BIRTH[ ]MALE [ ]FEMALEP lease list all people in the household:NAMEDATE OF BIRTHOCCUPATIONEDUCATIONF atherMotherOtherOtherOtherOtherHave there been any recent major changes or stresses in the child's life? [ ]YES [ ]NOIf YES, please explain:Does the child go to a baby-sitter, pre-school or day care regularly? [ ]YES [ ]NOBirth WeightLengthPlaceDuring the pregancy did the mother: (if YES, please explain)Have any medical problems?[ ]YES [ ]NOSmoke or drink?[ ]YES [ ]NOUse any medications?[ ]YES [ ]NOUse alcohol or other drugs?

2 [ ]YES [ ]NOHave problems with labor/delivery[ ]YES [ ]NOHow long did the baby stay in the hospital after birth?Is the child's general HEALTH : [ ]Good [ ]Fair[ ]Poor (check one)Does the child have any allergies? [ ]YES [ ]NOIs the child taking any medications? [ ]YES [ ]NOPlease list any hospitalizations, operations, serious illnesses or :Date:Has the child ever had any problems with the following?Eyes/Vision[ ]YES [ ]NOFeet[ ]YES [ ]NODigestion/Nutrition[ ]YES [ ]NOEars/Hearing[ ]YES [ ]NOUrine/Kidneys[ ]YES [ ]NOJoints[ ]YES [ ]NOSkin[ ]YES [ ]NOLungs[ ]YES [ ]NOTeeth[ ]YES [ ]NOHeart[ ]YES [ ]NOSeizures[ ]YES [ ]NORepeated Infections[ ]YES [ ]NOExplanationBIRTH HISTORYPAST MEDICAL HISTORYPEDIATRIC HEALTH HISTORY FORMNAME OF PATIENT ExplanationExplanationHave any of the child's brothers or sisters died?

3 [ ]YES [ ]NO(If YES, please give age and cause)Have any of the child's blood relatives had the following diseases: (If YES, please list family member)Heart Disease[ ]YES [ ]NOTuberculosis[ ]YES [ ]NOHigh Blood Pressure[ ]YES [ ]NOKidney Disease[ ]YES [ ]NOAllergies/Asthma[ ]YES [ ]NOCancer[ ]YES [ ]NODiabetes[ ]YES [ ]NOMental/Emotional Problems[ ]YES [ ]NOSickle Cell[ ]YES [ ]NOSeizures[ ]YES [ ]NODo you have any concerns about the following? (If YES, please explain)Development[ ]YES [ ]NOBehavior[ ]YES [ ]NOEating Habits[ ]YES [ ]NOSleeping Habits[ ]YES [ ]NOSchool Experience[ ]YES [ ]NOBathroom/Toilet Habits[ ]YES [ ]NODiscipline[ ]YES [ ]NOOther (explain)[ ]YES [ ]NODo you:Use Tobacco?

4 [ ]YES [ ]NODrink Beer or other Alcoholic Beverages?[ ]YES [ ]NOUse any kind of drugs?[ ]YES [ ]NO(For Females) How old were you when you had your first period?Are you sexually active?[ ]YES [ ]NOIf YES, do use birth control/protection?[ ]YES [ ]NOHave you ever been pregnant or fathered a child?[ ]YES [ ]NODo you have any concerns about the following? (If YES, please explain)Safety Issues[ ]YES [ ]NOSubstance Use (drugs, alcohol, tobacco)[ ]YES [ ]NOSexually Transmitted Diseases[ ]YES [ ]NOFamily Planning[ ]YES [ ]NOOther (explain)[ ]YES [ ]NOReviewed By:Date:DevelopmentExplanationIMMUNIZATI ONS WILL BE COPIED ON IMMUNIZATION RECORD BY OFFICE STAFFTHIS SECTION IS FOR TEENAGERS AND IS TO BE COMPLETED BY THE TEENF amily MemberFamily HISTORY