MEDICAL HISTORY FORM
Before the next visit to your child's physician, go over this checklist to remind yourself of events or symptoms that might be very important for accurate diagnosis and your child's future health care.
1. Has a doctor ever said your child has had the following: (Check all that apply.)
____ Allergies (asthma, hives, hay fever)
____ Rheumatic fever
____ Anemia ____ Pneumonia
____ Bleeding tendency ____ Heart murmur
____ Diabetes ____ Urinary infection
____ Convulsions
2. Is your child receiving medications for any of the above problems or any other
reasons? Yes ____ No ____ If yes, the medication and dose if possible:
Is your child allergic to any medications? Yes ____ No ____
Is your child receiving vitamins? Yes ____ No ____ If yes, what type?
3. Has your child been hospitalized at any time since birth? Yes ____ No ____
If yes, the hospital, date, and reason, if possible:
4. Has the child's school work been satisfactory this past year? Yes ____ No ____
As good as the previous year? Yes ____ No ____
If no, what do you think is the reason?
How many days was your child absent from school?
What was the major reason for the child missing school?
5. How many colds has your child had during the past year?
Were they severe? Yes ____ No ____ How long did they last?
6. Does your child appear to see and hear adequately? Yes ____ No ____
Has the child's vision and hearing been tested? Yes ____ No ____
If yes, when?
Has the child's hearing been tested? Yes ____ No ____ If yes, when?
Has the child complained of earaches? Yes ____ No ____
Draining ears? Yes ____ No ____
Nosebleeds? Yes ____ No ____
Sore throats? Yes ____ No ____
Red eyes? Yes ____ No ____
Do the child's eyes ever turn in or out? Yes ____ No ____
7. Does your child have a chronic cough? Yes ____ No ____
Does it awaken the child? Yes ____ No ____
Does it cause vomiting? Yes ____ No ____
Does the child have it now? Yes ____ No ____
Has the child ever been wheezing? Yes ____ No ____
Has the child had croup? Yes ____ No ____
Has the child experienced shortness of breath? Yes ____ No ____
8. Has your child ever had a heart murmur? Yes ____ No ____
When was it first heard?
Can the child run and play as well as friends of the same age?
Yes ____ No ____
Does the child tire easily? Yes ____ No ____
Does the child ever get a blue color to his skin? Yes ____ No ____
9. How is your child's appetite? ____ Good ____ Fair ____ Poor
Has the child lost weight recently? Yes ____ No ____
Has the child been troubled with:
Chronic diarrhea Yes ____ No ____
Vomiting Yes ____ No ____
Constipation Yes ____ No
Abdominal pain Yes ____ No ____
Hernia Yes ____ No ____
10. Does your son have a good urinary stream? Yes ____ No ____
Does your son or daughter urinate more frequently than normal?
Yes ____ No ____
Does the child complain of pain on urination? Yes ____ No ____
Has the child ever had blood or pus in an examined urine specimen?
Yes ____ No ____
11. Is your child's gait (manner of walking) normal? Yes ____ No ____
Does the child ever complain of joint pains? Yes ____ No ____
12. Does your child complain of headaches? Yes ____ No ____
Has there ever been a severe head trauma? Yes ____ No ____
Was the child unconscious during the trauma or at any other time?
Yes ____ No ____
Is the child nervous? Yes ____ No ____
Has the child ever had a convulsion with or without fever? Yes ____ No ____
Does the child have any of these habits:
____ Thumbsucking ____ Bedwetting
____ Temper tantrums ____ Watching TV excessively
____ Tics ____ Masturbating excessively
____ Inability to get along with other children
Are there any habits not mentioned that your child has? Yes ____ No ____
If yes, explain:
13. Is your child pale? Yes ____ No ____
Is the child susceptible to rashes? Yes ____ No ____
14. Has your child had any contagious diseases since last seen by a doctor?
Yes ____ No ____
If yes, which of these:
____ Chickenpox ____ Strep throat
____ Mumps ____ German measles
____ Measles ____ Roseola
____ Scarlet fever
15. In the past week, has your child had any of these symptoms:
____ Nasal congestion ____ Abdominal cramps
____ Cough ____ Fever
____ Sneezing ____ Rash
____ Diarrhea ____ Contact with contagious diseases
____ Vomiting
