PEDIATRIC MEDICAL HISTORY
I. Please tell us of your child’s birth history:
Birth Weight __________ ___Vaginal Birth ___C-Section Born at full-term ____ OR Premature ____(How many weeks early? _____)

Any complications at birth?____________________________________________ _______________________________________________________________________ _______________________________________________________________________

Current Age? ___years _____months Current weight? _______lbs.

II. Please circle any medical conditions relevant to your child’s history.

FREQUENT EARACHES                                                                     YES NO
SEIZURES                                                                                             YES NO
VISION PROBLEMS/GLASSES                                                          YES NO
ALLERGIES to _______________                                                       YES NO
ASTHMA or BREATHING PROBLEMS                                              YES NO
CHICKEN POX, MEASLES, MUMPS                                                 YES NO
FREQUENT OR SEVERE TEMPERATUES (OVER 101)                    YES NO
ILLNESS OR ACCIDENT RESULTING IN HOSPITALIZATION      YES NO

DATE HOSPITAL PROBLEM 1.________ ____________ _________________________________ 2.________ ____________ _________________________________ 3.________ ____________ _________________________________


III. Please list any Current Medications:______________________________ _____________________________________________________________