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MIT Medical Department

Pediatrics History Form

Dear Parent:
This is a health questionnaire on your child. Please complete this form. Bring it with you at the time of an
appointment.
Date completed:
Childs Name:
Contact Information for Parent 1
Name:
Home Address:
Home Phone:
Work Phone:
Contact Information for Parent 2
Name:
Home Address:
Home Phone:
Work Phone:
This child lives with:
Mother
Father
Mother/Father
MIT Affiliation
Person:
Position:

Date of Birth:
Email:
Cell/Other:
Email:

Mother/Partner

Cell/Other:
Father/Partner

Grandparent/Other

Department:

FAMILY HISTORY
1. Parent 1
Age:
Current Health:
Past Health Problems:
Ethnicity:
Education/Training:
2. Parent 2
Age:
Current Health:
Past Health Problems:
Ethnicity:
Education/Training:
3. Marital Status of Parents:
4. Other Children in Family:
Date of Birth
Gender
Name

Healthy or Medical Issues?

5. Are there cultural or religious practices that might affect your childs medical care?

no

yes

If yes, please explain (e.g. blood transfusion, dietary rules, etc.):

6. Is there tobacco use in/around your household?

no

yes

no
no
no
no

yes
yes
yes
yes

no
no
no
no
no

yes
yes
yes
yes
yes

7. Is there a history in the family/a blood relative of:


If yes, state relationship to child
a.
b.
c.
d.
e.

Allergies
Anxiety
Asthma
Birth Defects/Genetic Problems
Cancer
i.
Brain
ii.
Breast
iii.
Colon
iv.
Ovarian
v.
Skin

Version update 4/2013

f.

vi.
Thyroid
no
yes
vii.
Other (describe and state relationship to child):
Depression
no
yes

g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.

Diabetes
Hearing Loss
Heart Attack
Heart Disease
Hepatitis
High Blood Pressure
High Cholesterol
Learning Disability
Mental Illness
Seizures
Thyroid Problems
Tuberculosis

If yes, state relationship to child


no
no
no
no
no
no
no
no
no
no
no
no

PRENATAL HISTORY
1. While pregnant, did mother have:
a. Bleeding or spotting
b. German measles (Rubella)
c. Gestational diabetes
d. High blood pressure
e. Illness other than cold/flu
f. Kidney disease
g. Premature labor
h. Threatened miscarriage
i. Toxemia
2. Were medications or herbs taken during pregnancy?
If yes, what kind:
3. Was a fertility treatment used for this pregnancy?
If yes, what kind:
BIRTH HISTORY
1. Where was child born:
2. Was labor induced?
3. Was labor helped by medication?
4. Duration of labor:
5. Was child born early (less than 38 weeks)?
6. Was child born late (after 42 weeks)?
7. What was the method of delivery:
Breech
Caesarean (Please state reason):
Forceps
Spontaneous vaginal

yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes

no
no
no
no
no
no
no
no
no
no

yes
yes
yes
yes
yes
yes
yes
yes
yes
yes

no

yes

no
no

yes
yes

no
no

yes
yes

no
no
no
no
no
no

yes
yes
yes
yes
yes
yes

8. Childs birth weight:


9. Apgar Score (if known):
10. During the hospital stay, did child have any of the following:
a. Antibiotic treatment
b. Blue spells
c. Convulsions
d. Jaundice
e. Skin rash
f. Did child remain in hospital longer than mother?
11. How was/is baby fed?
Bottle
Breast

Version update 4/2013

DEVELOPMENTAL HISTORY:
1. At what age did child:
a.
b.
c.
d.

Age

Hold up head
Roll over
Sit unsupported
Stand alone
Age

e. Walk
f. Talk
g. Toilet train
h. Feed him/herself
i. Dress him/herself
IMMUNIZATIONS
PLEASE GIVE US A COPY OF PREVIOUS IMMUNIZATIONS/VACCINES
And TB (Tuberculosis) Testing or BCG Vaccination
PAST MEDICAL HISTORY:
1. Has the child had:
a. Blood: anemia (iron deficiency, Sickle Cell, Thalessemia)
b. Blood transfusions
c. Chicken pox (Varicella)
d. Contusions
e. Convulsions
f. Fractures
g. German Measles (Rubella)
h. Hospitalizations
i. Measles (Rubeola)
j. Meningitis
k. Mumps
l. Operations
If yes, what illness?
m. Poison ingestion
n. Other serious medical illnesses
If yes, what kind?
o. Is your child currently taking any medications, vitamins or herbs?
Medication

p. Reaction to medication or food (allergy)


If yes, please explain:
q. Any chronic or recurring pain?
If yes, please explain:
2. Eyes:
a. Any visual problems?
b. Do eyes look crossed?
c. Does the child wear eyeglasses?
3. Ears:
a. Any hearing problems?
b. Three or more ear infections?

Version update 4/2013

Strength/Dose

no
no
no
no
no
no
no
no
no
no
no
no

yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes

no
no

yes
yes

no

yes

no

yes

no

yes

no
no
no

yes
yes
yes

no
no

yes
yes

How Often?

4. Nose:
a. Does the child have frequent attacks of sneezing or rubbing his/her nose?
b. Has the child had frequent nose bleeds?
5. Throat:
a. Does your child have three or more strep throat infections per year?
6. Heart:
Have you ever been told your child has
a. A heart murmur?
b. Heart defect?
c. High blood pressure?
7. Lungs:
Has your child ever had
a. Asthma/wheezing?
b. Bronchitis or pneumonia?
c. Chronic cough?
8. Does your child tire easily?
9. Abdomen
Has your child ever had
a. Blood in bowel movement?
b. Difficulty with appetite or eating?
c.
d.
e.
f.

Frequent abdominal pain?


Frequent vomiting or diarrhea?
Jaundice?
Marked weight loss?
If yes, please explain:

10. Kidney:
a. Does your child ever complain of burning or frequency of urination?
b. Does your child wet the bed?
c. Has there ever been blood in the urine?
d. Has your child ever had a urinary tract infection?
11. Skin:
a. Acne?
b. Any sensitivity or allergy?
c. Eczema or atopic dermatitis?
12. Extremities:
Has your child
a. Had weakness or paralysis of arms or legs?
b. A persistent limp?
c. Every worn corrective shoes or braces?
13. Neurological:
Has your child ever had
a. Breath holding?
b. Convulsions or seizures?
c. Dizziness?
d. Fainting?
e. Frequent headaches?
f. Temper tantrums?
14. Is your child:
a. Impulsive?
b. Lacking in self-control?
c. Overactive?
d. Does your child have problems with:
i.
Attending school?
ii.
Attention span?
iii.
Learning?
iv.
Mood?
v.
Parents?
vi.
Peers?
vii.
Siblings?

Version update 4/2013

no
no

yes
yes

no

yes

no
no
no

yes
yes
yes

no
no
no
no

yes
yes
yes
yes

no
no

yes
yes

no
no
no
no

yes
yes
yes
yes

no
no
no
no

yes
yes
yes
yes

no
no
no

yes
yes
yes

no
no
no

yes
yes
yes

no
no
no
no
no
no

yes
yes
yes
yes
yes
yes

no
no
no

yes
yes
yes

no
no
no
no
no
no
no

yes
yes
yes
yes
yes
yes
yes

viii.
Sleep?
no
yes
e. Are there concerns about physical, sexual or emotional abuse?
no
yes
(You may call Mental Health Services to set up an evaluation at 617.253.2916 for any of the above.)
15. Has your child begun puberty?
no
yes
16. Any other concerns you would like to discuss?

_____________________________________________

_____________________________________________

Parent Signature

Provider Name

Version update 4/2013

Date

Date Reviewed