Medical history

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Patient's Name *

First

Last

Person completing form *

Date of birth *

Birth weight *

Length of pregnancy in weeks *

Relationship to patient *

Please explain any "yes" answers to the following questions about the patient.

Any problems with pregnancy, laboy, or delivery *

Comment *

Any congenital abnormalities? (present from birth or noted shortly after, and which have persisted?) *

Comment *

Any hospitalizations (overnight stays)? *

Comment *

Any surgery? *

Comment *

ANy history of head trauma or concussion? *

Comment *

Any history of seizures? *

Comment *

Elevated lead level? (over 10) *

Comment *

Sleep problems, including insomnia or loud snoring? *

Comment *

Any history within the past few years of poor growth? *

Comment *

Is the patient overweight? *

Is the patient underweight? *

Comment *

Has the patient had a school or sports physical, or an "annual exam" within the past two years? If not, the patient should have one scheduled. *

Comment *

Has the patient had an exam by an eye doctor within the past five years? *

Comment *

Did the patient pass the school hearing test? *

Comment *

Any chronic medical problems in the past that are now under control? *

Comment *

Is the patient on any medication(s) now, including over the counter medications and herbal remedies? *

Comment *

Does the patient have a history of any cardiac problems? *

Comment *

Any medical problems for which the patient is now being treated? *

Comment *

Allergies to medications? *

Which drug(s)? *

Describe the reaction(s) *

Any medications taken for psychological or behavior problems in the past? *

Type of problem being treated *

Please describe in following order: Medicine, Dose, How long on it, Effectiveness, Side effects *

Family History (includes patient's parents, grandparents, aunts, uncles and siblings)

Psychiatric problems? *

Please give relationship to patien, diagnosis, approximate age at diagnosis, need for psychiatric hospitalization, any medications that were noted to help the relative's condition, how the relative has done with regards to the illness in general. Problems would include ADHD, anxiety, depression, substance abuse. *

History of sudden death *

Comment *

Seizure disorders *

Comment *

Signature *

Max file size: 20MB

Date *

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Medical history

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