Wilson Care, Inc

Wilson Health Medical Group A Service of Wilson Health New Pediatric Patient Personal Medical History

Name ______Date: ______Last First MI

Date of Birth: _____ - _____ - _____ Sex: ____M ____F Last four of SSN # ______

Medical History 1. Please indicate if your child has had any of the following by placing an ‘X’ by the condition: _____ Blood Anemia _____ Convulsions/Seizures _____ Meningitis _____ Blood Transfusions _____ Fractures _____ Mumps _____ Chicken Pox _____ German measles _____ Poison Ingestion

If any of the above were checked please explain: ______List any other serious medical illnesses: ______

2. Eyes: a. Any visual problems?  Yes  No b. Do eyes look crossed?  Yes  No c. Does the child wear eyeglasses?  Yes  No 3. Ears: a. Any hearing problems?  Yes  No b. Three or more ear infections?  Yes  No 4. Nose: a. Does the child have frequent attacks of sneezing or rubbing his/her nose?  Yes  No b. Has the child had frequent nose bleeds?  Yes  No 5. Throat: a. Does your child have three or more strep throat infections per year?  Yes  No 6. Heart - Have you ever been told your child has: a. A heart murmur?  Yes  No b. Heart defect?  Yes  No c. High blood pressure?  Yes  No 7. Lungs - Has your child ever had: a. Asthma/wheezing?  Yes  No b. Bronchitis or pneumonia?  Yes  No c. Chronic cough?  Yes  No 8. Does your child tire easily?  Yes  No 9. Abdomen - Has your child ever had: a. Blood in bowel movement?  Yes  No b. Difficulty with appetite or eating?  Yes  No c. Frequent abdominal pain?  Yes  No d. Frequent vomiting or diarrhea?  Yes  No e. Jaundice?  Yes  No f. Marked weight loss?  Yes  No If yes, please explain: ______

Pediatric History 1 ______

10. Kidney: a. Does your child ever complain of burning or frequency of urination?  Yes  No b. Does your child wet the bed?  Yes  No c. Has there ever been blood in the urine?  Yes  No d. Has your child ever had a urinary tract infection?  Yes  No 11. Skin: a. Acne?  Yes  No b. Any sensitivity or allergy?  Yes  No c. Eczema or atopic dermatitis?  Yes  No 12. Extremities - Has your child: a. Had weakness or paralysis of arms or legs?  Yes  No b. A persistent limp?  Yes  No c. Every worn corrective shoes or braces?  Yes  No 13. Neurological - Has your child ever had: a. Breath holding?  Yes  No b. Convulsions or seizures?  Yes  No es c. Dizziness?  Yes  No d. Fainting?  Yes  No e. Frequent headaches?  Yes  No f. Temper tantrums?  Yes  No 14. Is your child: a. Impulsive?  Yes  No b. Lacking in self-control?  Yes  No c. Overactive?  Yes  No d. Does your child have problems with: i. Attending school?  Yes  No ii. Attention span?  Yes  No iii. Learning?  Yes  No iv. Mood?  Yes  No v. Parents?  Yes  No vi. Peers?  Yes  No vii. Siblings?  Yes  No viii. Sleep?  Yes  No e. Are there concerns about physical, sexual or emotional abuse?  Yes  No (You may call Mental Health Services to set up an evaluation at xxx-xxx-xxxx for any of the above.) 15. Has your child begun puberty?  Yes  No 16. Any other concerns you would like to discuss? ______

Prenatal History (Please complete if your child is one year or younger) 1. While pregnant, did mother have: a. Bleeding or spotting?  Yes  No b. German measles (Rubella)?  Yes  No c. Gestational diabetes?  Yes  No d. High blood pressure?  Yes  No e. Illness other than cold/flu?  Yes  No f. Kidney disease?  Yes  No g. Premature labor?  Yes  No h. Threatened miscarriage?  Yes  No i. Toxemia?  Yes  No 2. Were medications or herbs taken during pregnancy?  Yes  No If yes, what kind: ______3. Was a fertility treatment used for this pregnancy?  Yes  No If yes, what kind: ______4. Did you smoke or use any illicit drugs during this pregnancy?  Yes  No If yes, what kind:______

Pediatric History 2 Name ______

Birth History 1. Where was the child born: ______2. Was child born early (less than 38 weeks)?  Yes  No 3. Was child born late (after 42 weeks)?  Yes  No 4. What was the method of delivery: ___ Breech ___ Caesarean (Please state reason) ______Forceps ___ Spontaneous vaginal 5. Child’s birth weight: ______6. Apgar Score (if known): ______7. During the hospital stay, did child have any of the following: a. Antibiotic treatment?  Yes  No b. Blue spells?  Yes  No c. Convulsions?  Yes  No d. Jaundice?  Yes  No e. Skin rash?  Yes  No f. Did child remain in hospital longer than mother?  Yes  No 8. How was/is baby fed? ___ Bottle ___ Breast 9. If breastfed, were medications taken by the mother?  Yes  No If yes, what kind: ______

Allergies Please list all allergies, medications, seasonal and food; indicate reaction (use additional space at end if needed): Allergy Reaction

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Family History Please indicate below if your parents, siblings, child or grandparents have any of the following conditions by placing an ‘X’ by the condition and list the individual’s relationship (Father, Mother, Sibling, Child, Maternal or Paternal Grandparent) to you:

Condition Relationship Condition Relationship

___ Alcoholism or Drug dependency ______Heart Attack ______Anxiety ______High Blood Pressure ______Asthma ______High Cholesterol ______Birth defects/genetic problems ______Learning Disabilities ______Cancer ______Mental illness ______Diabetes______Thyroid problems ______

Pediatric History 3 ___ Hepatitis ______Seizures ______Heart Disease ______Tuberculosis ______

Who does the child live with? Check all that apply: ___ Father ___ Mother ___ Grandparents ___ Other: ______Father’s Name: ______Age: ______Father’s Education and Training: ______Mother’s Name: ______Age: ______Mother’s Education and Training: ______Marital Status of Parents: ______

Please list other children in the family along with their age and any medical issues: Name Age Medical Issues ______

Social History

What type of home do you live in? (Please circle one) Apartment House Homeless Homeless Shelter Group Home Does your child drink city or well water?  Yes  No Are there any firearms in the home?  Yes  No Does your child currently use tobacco products?  Yes  No Does anyone in your home smoke?  Yes  No If ‘Yes’, do you smoke in the home or car? ______Does your child drink caffeine?  Yes  No If ‘Yes’ how much do you drink? Daily ______Weekly ______Does your child ride in an age appropriate restrain in the care?  Yes  No Does your child wear a bike helmet when riding a bike?  Yes  No Does your child know how to swim?  Yes  No Does your home have smoke detectors?  Yes  No Is your home child proof?  Yes  No

Medications Clearly list all medications your child takes, including prescriptions, over the counter, vitamins, herbs, birth control etc. (use additional space at end if needed): Name of Medication Dosage How often do you take? (Ex: 2 times a day or every other day) ______

Pediatric History 4 ______

Name ______

Surgical/Procedure History Please list any surgeries or procedures and the dates below (use additional space at end if needed) that your child has had: Surgery/Procedure Date ______

Do you or any family member have complications with anesthesia?  Yes  No Have you ever been told that your child needs to take antibiotics before surgery?  Yes  No If ‘Yes’ why? ______

Please list any other concerns or conditions that would affect the care we provide your child (ex. Hearing loss)

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Pediatric History 5