Pediatric Medical History

February 23, 2012
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PEDIATRIC MEDICAL HISTORY QUESTIONNAIRE

Pediatric Medical History Questiionnaire

Name:

Date of Birth:

Select Date

Age:

Date of Appointment:

Select Date

REASON FOR YOUR VISIT TODAY?:

Family Physician:

Pediatric Specialist: (Any cardiogist or specialist your child may be seeing for a specific health problem):

Allergies (Drug, Food & Inhalant):

Allergies (Drug, Food & Inhalant)	Reaction

In the past 12 months has this child had...

6 or more ear infections:

yes No

6 or more sinus infections:

YesNo

4 or more sore throats requiring antibiotics:

YesNo

Number of sore throats not needing antibiotic:

Please check yes or no if your child has had any of the following surgeries:

Submit