Pediatric Health History Today's Date MM slash DD slash YYYY Family Care Clinic location you are registering for: Family Care Clinic - Hospital, Professional Office Building 1 Family Care Clinic - Main Avenue SW Patient InformationChild's NameFirst* FirstMiddle MiddleLast* LastNickname* Date of Birth MM slash DD slash YYYY Gender Male Female Previous Primary Care Physician Request for Records Transfer Complete? Yes No Date of Last Well Child Exam Mother's Full Name Father's Full Name Step-Mother's Full Name (If applicable) Step-Father's Full Name (If applicable) Custodial Provider's Full Name (If different from above) Relationship to Patient Email Birth HistoryBirth Weight Pregnancy # Mom's age Was the birth: Vaginal Cesarean Early Late If the birth was early, how many weeks early? If cesarean, why? Did mother have any illnesses/problems with her pregnancy? Yes No If yes, please explain. Did the baby have any problems right after birth? Yes No If yes, please explain. Before mother knew she was pregnant or at anytime during her pregnancy, did she: Smoke cigarettes Use "street" drugs Drink alcohol Use prescription drugs If you checked any of the above, please explain.Was the initial feeding: Breast Milk Formula Current and Past HistoryIs your child currently on any medication? Yes No Does your child have any serious or chronic illnesses? Yes No Has your child had any serious injuries or accidents? Yes No Has your child had any surgeries? Yes No Has your child ever been hospitalized? Yes No Is your child allergic to any medications? Yes No Has your child ever reacted to immunizations? Yes No If you answered yes to any of the Current and Past History questions, please explain below.Does your child have or has your child ever had: Asthma, recurrent cough, bronchitis, or pneumonia Nasal allergies or eczema Frequent ear infections or sore throat Problems with ears or hearing Problems with eyes, vision or teeth Frequent headaches or other neurological problems Frequent abdominal pain Constipation requiring doctor visits Bladder/kidney problems or bedwetting Any heart problems/murmur Anemia or bleeding problem Thyroid or other gland problem Diabetes ADD/ADHD Mental health issues Use of drugs or alcohol If you answered yes to any of the above illnesses or conditions, please explain.Household InformationPlease list all those living in the child's home (Click plus sign to far right to add additional rows)NameRelationship to ChildDOB Add RemoveAre there siblings listed above? If so please list their full names, ages and where they live.Child Care: Smokers in household? Yes No Family Medical History (Parents, Siblings, Grandparents, Aunt and Uncles)Have any family members had the following? (Check all that apply) Alcohol/Drug Use Allergies Asthma Birth Defects Blood Disorders Bone Disorders Cancer Diabetes Endocrine Disease Ear/Nose/Throat Disorders Eye Disorders Gastrointestinal Disorders Heart Disease High Blood Pressure High Cholesterol Immune Disorders Joint Problems Kidney Disease Liver Disease Lung Disease Migraine headaches Metabolic disorders Obesity Seizure disorders Skin disorders Stroke history Thyroid disorders Mental health history Other medical history If you checked any of the above, please explain below.