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Lansdowne Park Pediatrics

Helping Children & Families Stay Healthy

Medical History Form

Patient First & Last Name*

Patient's Birthday*

Month

Day

Year

Name of person completing this form & relationship to child*

Email address*

Previous Physician

Physician's Phone Number

Birth History:

Full term?*

Yes

No

Delivery?*

Vaginal

C-section

Birth Weight*

If premature, at what week was child born or what was the due date

Did the baby pass the hearing test?*

Yes

No

Did the baby require phototherapy?

Yes

No

Unsure

Problems during pregnancy?*

Yes

No

Problems during delivery?*

Yes

No

Problems in the first month?*

Yes

No

Medical problems?

Has your child ever been hospitalized?

Yes

No

If yes, please list ages and for what?

Has your child ever had surgery?

Yes

No

If yes, please list ages and for what?

Has your child had any accidents?

Yes

No

If yes, please list ages and for what?

Immunization, Allergies & Medications:

Are immunizations up to date?

Yes

No

Allergy to food?

Yes

No

If yes, please list

Allergy to Medicine?

Yes

No

If yes, please list

Allergy to Latex?

Yes

No

Current medications, please list

Developmental History:

At what age did your child sit up?

At what age did your child walk?

At what age did your child say their first word?

At what age did your child start toilet training?

Social History:

Who lives in the home with your child?

Are there any pets? Please list

Anyone living in the household who smokes? (Inside or outside the house)

Yes

No

If your child resides in multiple homes, who lives in other home(s)?

Are there any pets in the other home?

Anyone who smokes at the other home? (Inside or outside the house)

Yes

No

Does your child attend daycare?

Yes

No

If yes, what is their schedule?

Does your child have a babysitter?

Yes

No

If yes, what is their schedule?

School History: (if applicable)

What grade is your child in?

What school does your child attend?

How is your child's performance?

Poor

Fair

Average

Excellent

Does your child have an IEP or 504 Plan?

IEP

504 Plan

If yes, please detail

Check if there is a family history of: (include grandparents, aunts, uncles, cousins...)

Asthma

Allergies

ADHD

Arthritis

Anxiety

Cancer before 60

Depression

Diabetes

Early heart attack or sudden death

Heart Disease

High Blood Pressure

Learning problems

Obesity

Seizures

Sickle Cell Trait or Disease

Stroke before 60 years old

Thalassemia Trait or Disease

Thyroid problems

Other

Please list family member and what they have a history of or if you selected other, please list

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