Youth Care / Same Day Care

NEW PATIENT MEDICAL/FAMILY HISTORY 

Mothers name                                                                          Age                              NAME                                                 

Occupation                                                                                                                    BIRTH DATE                                      

Fathers name                                                                            Age                             DATE                                                    

Occupation                                                                                                                 
A.   PREGNANCY AND BIRTH:
1.   Where was the baby born?                                                                                         
2.   Mother’s age at birth                                                                                                     
3.   Did mother have any illness during pregnancy?           No       Yes
4.   Did she take any medications other than vitamins and iron?                     No       Yes
5.   Was the baby on time?                    Yes       No
6.   What was the birth weight?                                                                                                    
7.   How long did the infant stay in the hospital?                                                                                          
8.   Did the baby have any trouble while in the hospital?   (Jaundice, infections, other?)        No       Yes
           What Kind?                                                   
                                                                                      

B.   PAST MEDICAL HISTORY:
1.   Where has your child gone for checkups until now?                                                                                            
2.   Date of last checkup:                                                                                                        
3.   Date of last dental checkup:                                                                                                    
4.   Has your child had allergic reactions to any medications, foods, insect bites?                  No       Yes
        Which ones?                                          
5.   Has your child had reactions to any immunizations?           No       Yes
        Which ones?                                          
6.   Do you have a record of immunizations?              Yes       No
7.   Any hospitalizations other than for birth?             No       Yes
        Which kind?                                          
8.   Any serious injuries?                No       Yes
        Which kind?                                          
9.   Are any medications taken regularly?            No       Yes
        Which ones?                                          
10. Has your child seen a doctor for any problem on a regular basis?                     No       Yes

C.   FAMILY HISTORY:

1. Are the child’s parents both in good health?           Yes       No
2.  Circle any diseases that this child’s parents, grandparents, brothers, sisters, or aunts and uncles have had:  anemia, asthma, allergies, diabetes, high blood pressure, heart trouble, tuberculosis, mental illness, drug problems, alcohol problems, inherited illness, cancer, AIDS, others
3.   List age, sex, and general health of brothers and sisters                                                                                         

                                                                                        
4. Have any of your children died?               No       Yes

D.   FEEDING AND NUTRITION:
1.   Is your child’s appetite usually good?              Yes       No
2.   Is it good now?        Yes       No
3.   Was there severe colic or any unusual feeding problem during the first 3 months?        No       Yes
4.   Do any foods disagree with him/her?                No       Yes

5.   For the first 6 months, is he/she (was he/she) breast fed or bottle fed?

                                                                                         
6.   If still on formula, which one do you use?                                                                                         
7.   Does he/she take vitamins?        Yes       No

E.   REVIEW OF SYSTEMS:
1.   Has your child had frequent ear infections?           No       Yes
2.   Any eye problems?               No       Yes
3.   Has he/she had any problems with teeth?             No       Yes
4.   Does he/she have frequent colds or sore throats?         No       Yes
5.   Is there asthma, pneumonia, or recurrent cough        No       Yes

6.   Does he/she have a heart murmur or any heart problems? 

        No       Yes
7.   Any problems with urination or urinary infection?          No       Yes
8.   Any problems with diarrhea or constipation?        No       Yes

9.   Have there been any convulsions or other problems with the nervous system?        

        No       Yes
10. Any eczema, hives, or other skin condition?          No       Yes
11. Has your child ever been anemic?          No       Yes
12. Please list any other medical problems:                                                                                         

                                                                                        

                                                                                        

F.   DEVELOPMENT/BEHAVIOR:
1.   At what age did your child sit alone?                                                                                         
2.   At what age did he/she walk alone?                                                                                         
3.   Did he/she say any words by the time he/she was 1½ years old?        Yes       No

4.   How does this child compare to others his or her age?

                                                                                         
5.   What grade is he/she in?                                                                                          
6.   Has he/she had any trouble in school?         No       Yes

7.   Circle if your child has had any of the following: 

 nail biting, thumb sucking, bed wetting, problems with toilet training, bad temper, hyperactivity, nightmares, speech problems, problem with discipline, any emotional problems.

G.   SAFETY/ENVIRONMENT:
1.   Do you live in a:  private house, apartment, mobile home, other (CIRCLE)

2.   Do you know the hottest temperature of the water in your pipes? 

        Yes       No

3.   Is there a working smoke alarm on each floor in the house?               

        Yes       No

4.   Does your child always use a car seat/seat belt when riding in a car?

        Yes       No

5.   Are there any smokers in the household?

        No       Yes
6.  Does your child always wear a   helmet when riding his/her bicycle?         Yes       No

SOCIAL HISTORY:
1.   With whom does the child live?                                                                                         

2.   Is your child in day care or at a sitter?  

        No       Yes
Where?                                             
   
SPIRITUAL HISTORY:  
Research shows that spirituality or faith can have a positive impact on health. If you feel comfortable, please answer the following questions to help me understand the role of spirituality and faith in your life.
1. Do you attend religious service?        Yes       No
2. If so, how often? ______ time(s) per day / week / month / year
3. If you have a religious/spiritual preference, what is it?                                                                                         
4. Do you pray?        Yes       No
5. Are there any aspects of your religion/spirituality that I should be aware of in caring for your family?
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6. How important is faith/spirituality to you?
  very little      somewhat      quite a bit      a great deal