Patient History- Pediatric Patients

First Name

Last Name

Date of Birth

Age

Primary Care Provider

Referring Provider

Chief Compliant

How long?

Current Medication List (Include Medication Name, Dosage, & Frequency)

Drug Allergies - Medication & Reaction

Past Medical History

If cancer, what type?

Past Surgical History

If other, what type of surgery?

Past Hospitalizations (List below with dates and include child birth)

If yes cancer, type

Social History

Pediatric exposed to vape/cigarettes? Yes or No

School

Daycare/Preschool

Grade School

If in K-12 what grade?

Loss of school in past year? If so, how much?

Do you have problems with water leaks, wet spots, or mold in your home? Yes or No

Do you have pets in your home? Yes or No

Type

Amount

Alcohol usage during pregnancy. Yes or No

Alcohol Usage

Currently Every Day

Currently Some Days

Former

Never

If currently every day amount and type:

If former, quit date?

Tobacco usage during preganancy, Yes or No

If currently every day amount and type:

If former, quit date?

Siblings? If so, how many

Pacifier User, Yes or No

Please check and symptoms that patient is experiencing currently.

Other

Endocrine

Excessive thirst or urination

Adrenal Gland Problems

Weight gain/ loss

Patient His­to­ry- Pedi­atric Patients