1. Birthplace _____________________________
2. Was pregnancy normal? ________________________________________________
3. Was delivery normal? __________________________________________________
4. Was baby full term? ___________________________________________________
5. Birth weight _________________ 6. Birth length ___________________________
7. Any problems in nursery?
8. Breast fed or bottle fed? ________ 9. Any feeding problems?__________________
1. Ages when first:
Sat _____________ Crawled ___________ Rolled ____________ Walked _________
First Teeth ____________ Toilet Trained ___________
2. School History:
Year in school ___________ Nursery ___________
Grades Averaged ____________ School Name _______________________________
School Problems _______________________________________________________
_____________________________________________________________________
Attends special school or classes? _________________________________________
_____________________________________________________________________
Discipline or behavior problems? __________________________________________
____________________________________________________________________
Ever seen by psychologist, speech therapist or special teachers? _________________
____________________________________________________________________
(When, Where, Why?) __________________________________________________
____________________________________________________________________
____________________________________________________________________
E. Serious Injuries
(When, Where?) _______________________________________________________
____________________________________________________________________
F. Allertic Reactions
(Drugs, Asthma, Hives, Eczema, Hay Fever, Food) _____________________________
___________________________________________________________________
G. Family History
1. Father: Living? _______ Age now __________ Health ________________________
2. Mother: Living? ______ Age now __________ Health _________________________
3. Brothers/Sisters _________ How Many _______________
Ages _______________________________________________________________
Healthy? _____________________________________________________________
4. Any family history of:
Diabetes ___________________________ Allergies __________________________
Convulsions ________________________ Heart Disease _______________________
TB _______________________________ Cancer_____________________________
Other ________________________________________________________________
H. Past Medical History
1. Any problems with:
Sleeping ______________________________
Bedwetting ____________________________
Weight ________________________________
Height _________________________________
Nail Biting ______________________________
Nightmares _____________________________
2. Diet:
Any colic problems? _________________________________________________
Use special diets? ___________________________________________________
Taking vitamins regularly? ____________________________________________
Taking fluoride? ____________________________________________________
3. Contagious diseases (what age?)
Measles________ Mumps _________ Rubella (German Measles) _____________
Chicken pox _________ Scarlet fever __________ Other ____________________
4. Immunizations (please give age and/or dates)
DPT series _____________ Boosters ___________________________________
Polio series ____________ Boosters ___________________________________
Measles, Mumps Rubella ____________________________________________
TB Test _______________________ Others ____________________________
5. Medications (Does your child take any now?)
_______________________________________________________________
I. Demographics
How long has your family lived in this area? ______________________________
Where did you live before coming to this area? ____________________________
Travel outside the US (When and where) ________________________________
J. General Survey
Has your child had any unusual problems with the following?
Head _________________________ Eyes _____________________________
Ears/Nose/Throat_________________________________________________
Chest/Ribs/Sternum _______________________________________________
Heart ________________________ Lungs ____________________________
Stomach _____________________ Kidneys ___________________________
Bladder _____________________ Skin ______________________________
Bones/Muscle/Joints _____________________________________________
Blood ______________________
When was your child's last blood test? _______________________________
When was your child's last urine test? ________________________________
K. Any Special Comments About Your Child?
______________________________________________________________
______________________________________________________________
L. Your Chid's Last Doctor's Name and Address
______________________________________________________________
______________________________________________________________
Person Completing Form:
Name: _________________________________________
Signature: ______________________________________
Relationship to patient: ____________________________
Date: __________________________________________
