Illini Pediatrics LLC, DBA Ideal Pediatrics

Health History

Patient name Date of Birth Form Completed By: Today's Date

Child's Household Information

List of all living in home

What is the child's living situation if not with biological parents? If one or both parents are not living in the home, how often does the child see the parent(s) not in the home?

Birth History

Birth Weight Gestational age at birth? Was the delivery: If cesarean, why? Were there any prenatal or neonatal complications? If yes, explain

During pregnancy, did mother:

Use tobacco drink alcohol Use drugs or medications use prenatal vitamins Was initial feeding: Did baby go home with mother from the hospital?

General

Do you consider your child to be in good health? If no Explain Does your child have any seriously illnesses or medical conditions? If yes, explain. Has your child had any surgery. If yes, please list what and dates. Has your child ever been hospitalized. If yes, when, where and why. Is your child allergic to medicine or drugs? If yes, what? Do you feel your family has enough to eat?

Biological family history

Mark any the occurred in immediate family members under the age of 55. From the above list, please name which family members were diagnosed with the mentioned illness.

Past History

Does your child have, or has your child ever had: If any of the above were checked, please explain in further detail when and what the issue was/is.

for girls:

Have you had your first period? Age of first period: Any problems with period?