Child's Surname First name  Middle initial

Address

Referral Source: Patient  Friend Another Doctor Other

List the child's current physicians

Has the child ever been to an Emergency Room (ER) for treatment in the last year? Yes No
How many times in the past year?

List the reason and when you made each ER visit

Has the child ever stayed in the hospital overnight during the past year? Yes No
How many times in the past year?
List the reason and date the child stayed overnight

Health of Mother During Pregnancy (Prenatal) -- select by clicking

weight gain diet pre-natal vitamins infections (specify) vaginal bleeding pre-eclampsia medication X-Rays recreational drugs (specify) alcohol smoker  passive smoke within home
duration of pregnancy (no. of weeks)
planned pregnancy?  Yes No

Delivery (Natal)

type of delivery vaginal forceps C-Section other difficult delivery
type of analgesia epidural general anesthetic nerve block other none
birth order if a multiple birth how long in hospital
mother's health postpartum
separation of mother and infant and reasons
initial reaction of mother to baby
nature of bonding

Newborn (Neo-natal)

birth weight APGAR score estimation of gestational age onset of respirations problems with feeding
breathing problems
rashes birth injury bluish skin (cyanosis) greenish skin (jaundice) pale skin (anemia) convulsions congenital anomalies or infection feeding problem abnormal crying pattern abnormal sleeping pattern  problems urinating problems passing stool (defecating) weight loss hemorrhagefever

Feeding History (Nutrition): especially important during the first two years of life regarding failure to thrive and overnutrional states

Infancy

1. Breastfeeding
a. frequency--about every hours 
b. duration--about minutes)
c. feeding problems: vomits colic diarrhea other--specify
d. supplements:  vitamins other--specify

2. Artificial Feeding
a. type of milk (e.g. Enfilac, Similac, Soya, other) Specify
b. frequency: about every hours
c. duration: about minutes)
d. feeding problems:  vomits colic diarrhea other (Specify )
e. supplements: vitamins other (Specify )

3. Solid Foods
a. When introduced: about months) 
b. What type (e.g. cereal, fruits, vegetable, meat, other): Specify
c. Amount of food:  infant's response

4. Self feeding: good eater needs help (Specify )

Childhood Eating Habits

1. Breakfast time: about AM duration
fruit juice milk (type ) cereal egg bread sugar other  (Specify ) location (in front of TV?):

2. Lunch (time: about AM/PM duration
fruit juice milk (type ) vegetable bread egg cheese meat desert other: (Specify) location (in front of TV?)

3. Dinner (time: about PM; duration
fruit juice milk (type ) vegetable bread cheese meat desert other: (Specify  ) location (in front of TV?):

4. Snacks ( frequency /day) fruit juice vegetable chocolate candy pop junk food other (Specify )

Growth and Developmental History: This is very important during infancy and childhood and in dealing with problems of delayed physical growth, psychomotor and intellectual delay, and behavioral difficulties

Physical Growth

1. Height (actual or estimate in inches or cm.) at: 
birth 1 yr 2 yr 3 yr 5 yr 10 yr  

2. Weight (actual or estimate in pounds or kgs.) at:
birth 1 yr 2 yr 3 yr 5 yr 10 yr  

Developmental Milestones

1. Motor

a. When did child roll over front to back & back to front?
b. When did child sit up without support (avg. 6 mo.)
c. When did child first walk (avg. 12 mo.)
d. When did child kick or throw ball overhand (avg. 2 yr.)

2. Language:
a. When did child turn head to voice (avg. 6 mo.)
b. When did child say "mamma" or "dadda" (avg. 1 yr.)
c. Name photos or body parts (avg. 2 yrs.)

3. Personal Care:
a. Self feeds crackers (avg. 7 mo.)
b. Drinks from a cup (avg. 14 mo.)
c. Toilet trained (avg. 2 - 3 yrs.)

Social Development

1. Sleep Patterns
a. Daytime naps (about minutes; times per day 
time of naps location (crib, couch, bed, other
b. Bedtime routine: type of bed guard rails: Yes No location
onset of sleep:  minutes duration hours regular intermittent nightmares terrors night light humidifier bottle other: Specify

2. Toileting
a. Methods of training used
b. When did child attain: bladder control bowel control
c. bedwetting (enuresis) fecal soiling (encoporesis)

3. Speech
a. Hesitation stuttering baby talk lisping
b. Estimate number of words in vocabulary

4. Habits
a. bed rocking head banging tics ritualistic behavior 
b. thumb sucking nail biting tries to eat inedible items (pica)

5. Discipline
a. Caregiver's estimate of child's temperament and response to discipline:
b. Methods used: time out removing privileges avoidance firm talking to spanking
other: Specify  
c. response to discipline: success failure temper tantrums withdrawal aggressive behavior
other: Specify

6. Schooling
a. Day Care: age; adjustment upon entry
b. Nursery School: age; adjustment upon entry
c. Kindergarten: age; adjustment upon entry
d. Current parental satisfaction child satisfaction
e. Any school concerns

7. Play
a. Does the child play regularly: Yes No For how long? 
b. Types of play; plays alone; with others
c. How does child get along with others
Any concerns: Specify

8. Telecommunications
a. How much TV per day: supervised: TV in bedroom Yes No
b. Types of programs; educational violent adult content
c. Internet: supervised adult filters
d. Cell Phones; hrs per day pager

9. Sexuality
a. Curiosity regarding: gender differences masturbation wet dreams (nocturnal emissions) menstruation conception sexual relations secondary sexual characteristics and hormonal urges
b. Caregiver's response:
age appropriate
books
school
avoidance
other: Specify  

10. Personality
a. Relationship with: caregivers siblings friends
teachers
b. Degree of independence
group interests
solo interests
c. Friends: Special friends (real imaginary)

11. Self Esteem
Confident feels good about self shares with others caring loving and considerate forgiving learns from errors tries to improve self

Childhood Illnesses

frequent ear infections (otits media) frequent sore throats tonsils measles mumps rubella chicken-pox diphtheria pertussis scarlet fever other: (Specify )

Past Surgical History: List Operations (include include childhood tonsils, appendix, fistula, hernias, club-foot, etc.)

                                                             Childhood Vaccine History

Enter the date and name the physician giving the following vaccines:

Has the child ever had any blood transfusion(s) Yes No
If so, when, where, and how many units?

List any allergies the child has had to food or medications (Summarize)

Has the child ever had an anaphylactic reaction (turning red, difficulty breathing, generalized swelling up)? Yes No

Present Prescription Medication (include OTC products, vitamins, inhalers, creams):

Drugs, dosage, and how often the child takes them.

To avoid errors, bring in any medications with you in their original bottles.

Accident History

 Falls fractures cuts burns bites
other unexplained injuries

Safety History

Car Seat pets protective clothing (e.g. helmets, gloves, etc.)

Family History

Parent's Relationship: Any blood relations (consanguity) amongst the parents?  Yes No
Specify

1. Mother:

Mother's Date of Birth

Mother's Education

Mother's Occupation

Mother's Religion (optional)

Mother's General Health

history of heart disease (rheumatic fever, valvular heart disease) high blood pressure diabetes thyroid kidney cancer (breast, bowel) tuberculosis fibrocitis stroke arthritis blood disorders (thallasemia, sickle cell, galactosemia, phenylketonuria, alpha1 antitrypsin deficiency) other genetic metabolic disorders neural tube defects Down's syndrome autism migraines mental illness (e.g. depression, mania, schizophrenia) substance abuse (e.g. cocaine, alcoholism) or other illnesses, list them below.

2. Father

Father's Date of Birth

Father's Education

Father's Occupation

Father's Religion (optional)

Father's General Health

history of heart disease (rheumatic fever, valvular heart disease) high blood pressure diabetes thyroid kidney cancer (prostate, bowel) tuberculosis fibrocitis stroke, Arthritis blood disorders (thallasemia, sickle cell, galactosemia, phenylketonuria, alpha1 antitrypsin deficiency) other genetic metabolic disorders neural tube defects Down's syndrome autism migraines mental illness (e.g. depression, mania, schizophrenia) substance abuse (e.g. cocaine, alcoholism) or other illnesses, list them below:

Review of Organ Systems

General: changes in weight growth change fever puberty hyperactive Attention deficit
Skin:  rashes lumps moles birth marks suspicious bruises 
Head:  headache  head injury
Eyes: crossed-eyes (strabismus) lazy eye red eye eye pain running eyes 
Ears: decreased hearing ear pain (otolgia) discharge protruding ears red ears
Nose and sinuses: pain swollen discharge nosebleed (epistaxis) frequent colds nasal stuffiness hay fever  sinus trouble
Mouth and throat: teething frequent sore throat bleeding gums last dental exam
Neck:  lumps in neck  "swollen glands" goiter stiff neck
Breasts:  lumps pain discharge 
Respiratory: cough phlegm (sputum) green sputum (purulent) clear foamy sputum (mucoid) spitting up blood (hemoptysis) shortness of breath wheezing asthma
Cardiovascular: chest pain shortness of breath (dyspnea) rheumatic fever heart murmur weakness dizziness loss of consciousness (syncope)
Peripheral Vascular (Circulation):  cold or bluish extremities (cyanosis)
Gastrointestinal: nausea vomiting vomiting up blood (hematemesis) diarrhea constipation anal fissure hepatitis or other liver disease food intolerance abdominal pain passing blood per rectum in stools (hematochezia - bright red blood melena - black tarry stools)
Urologic: frequent urinating sense of urgency urinating excessively at night (nocturia) 
pain or difficulty urinating (dysuria) blood in urine (hematuria)  bed-wetting (enuresis) foul odored urine (stranguria) history of inguinal hernias 
Male Genital System:  pain in testis lump(s) in testis undescended testis circumcised abnormal genitalia
Gynecologic (female genital) system: 
Onset of periods (menarche) Last menstrual period
Periods intervals : regularity   frequency duration
Flow: heavy medium light cramps PMS sexually active abnormal genitalia
Musculoskeletal: walks with limp guards/protects a particular limb injury/accident joint pain (arthralgias) joint stiffness (juvenile rheumatoid arthritis  muscle pains (myalgias) fever joint swelling joint deformed history of domestic violence 
Neurologic: headache brain tumor fainting blackouts (syncope) seizures febrile seizures weakness  numbness paralysis cerebral palsy muscular dystrophy spasms (dystonias) nerve pain altered personality confusion poor memory
Psychologic: nervousness tension high stress depressed poor sleep (insomnia) 
mania psychosis confusion poor judgement poor memory 
poor insight delusional hallucinations hear voices feels out of control impulsive self destructive suicidal feelings or tendencies feelings to hurt or harm others despondent withdrawn helpless hopeless frustrated angry rage history of substance abuse 
Endocrine (Hormones): thyroid problem heat or cold intolerance excessive sweating Type 1 diabetes excessive thirst excessive hunger excessive urination excessive hair (hirsuitism) rapid change in growth (acromegaly, dwarfism) ambiguous genitalia (hypothalamic, adrenal, or gonad imbalance)
Hematologic: anemia thallassemia easy bruising (hemophilia easy bleeding (gums, nose, rectum, urine) fever weight loss pneumonias leukemias

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