Patient Medical History - Spring Valley Pediatrics

Patient's Name*

First Last

Date of Birth*

Completed By*

Date of Completion*

Household

Please list all those living in the child’s home (Name, Relationship to child, Date of birth, Health problems):

Birth History

Birth Weight

How many weeks gestation?

Did mother have any problems during pregnancy?

During pregnancy did mother...

drink alcohol?
smoke?
use any drugs or medications?

If yes, please list drug(s) or medication(s)

Was delivery...

Vaginal?
C-section?

If C-section, for what reason?

Did baby have any problems right after birth?

Was initial feeding

breast?
bottle?

Did baby come home with you from the hospital?

General

Please provide details as necessary.

Does your child have any serious medical condition?

Yes
No

If yes, please list

Has your child has serious injuries or accidents?

Yes
No

If yes, please list

Has your child had any surgery?

Yes
No

If yes, please list

Has your child ever been hospitalized?

Yes
No

If yes, please list

Is your child allergic to medications?

Yes
No

If yes, please list

Is your child currently on any medications?

Yes
No

If yes, please list

Do you have any feeding or nutritional concerns?

Yes
No

If yes, please list

Has your child had any growth problems?

Yes
No

If yes, please list

Is your child up to date on immunizations?

Yes
No

If yes, please list

Development

Are you concerned about your child’s development?

Yes
No

If yes, please give more details

Are you concerned about his/her attention span?

Yes
No

If yes, please give more details

How is his/her behavior in school?

Has he/she failed or repeated a grade in school?

How is he/she doing academically?

Is he/she in any special or resource classes?

Past Medical History

Does your child have, or has he/she ever had the following? If so please provide details in the box below:

Please provide details here:

Please bring a copy of your child’s immunization record to your first appointment at Spring Valley Pediatrics.

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Patient Medical History Form

Household

Birth History

General

Development

Past Medical History

Please bring a copy of your child’s immunization record to your first appointment at Spring Valley Pediatrics.

Spring Valley Pediatrics

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