Pediatric Medical History Form
This is to be completed prior to your first visit to help guide and streamline your care.
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Email *
Patient Information
Please complete the following information about the patient.
First Name *
Last Name *
Date of Birth *
Please list any daycare or school they attend and their grade.
(e.g., Star High School, 9th grade; Children's Daycare Center, 0-1 year old class; at home with dad)
 *
Please list the individuals that live at home with your child, including pets.
(e.g., at dad's home - grandma, dog (Lucy); at mom's home - 5 year old brother)
 *
Please list any known allergies and their reaction when exposed? 
Write "N/A" or "none" if you have no allergies.
(e.g., latex - hives; shellfish - anaphylaxis, sulfa drugs - rash) 
 *
Please list any medications, vitamins, or supplements your child is currently taking and include their dosage and frequency.
Write "N/A" or "none" if you are not taking any.
(e.g., Flintstones multivitamin - 2 with breakfast, albuterol inhaler - as needed, Zyrtec 5mg - once daily)
 *
Does your child have or has s/he ever had any of the following conditions?
Column 1
Seasonal allergies
Frequent ear infections
Problems with eyes or vision
Asthma/Reactive Airway Disease
Heart problems including murmur
Anemia or bleeding problems
Frequent abdominal pain
Constipation or diarrhea
Bladder or Kidney infection
Chronic skin problems (acne/eczema, etc)
Frequent headaches
Seizures or other neurological problems
Chicken Pox
Diabetes
Thyroid problems
Use of alcohol or drugs
(girls) Started menstrual cycle
(girls) Any problems with her periods
Please list any previous surgeries or operations with approximate dates. 
Write "N/A" or "none" if you have not had any surgeries.
(e.g., inguinal hernia - 10/2022, mole removal - 6/2020)
 *
Please list any hospital admissions with approximate dates and reason for hospitalization. 
Write "N/A" or "none" if you have not had any hospitalizations.
(e.g., asthma - 2015, mesenteric adenitis - 2010)
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