graphic: kids

Is Your Child Sick?TM

Emergencies

Medical Emergency:
Poison Control:

Office After Hours:
Call 911
(800) 222-1222

(808) 524-2575

Past Medical History Form (2 Months and Older)



























Parent’s marital status:





CHILD'S MEDICAL HISTORY:





CHILD'S MEDICAL HISTORY:

Has your child ever had or been treated for the following

Allergies, sinus:


Food allergy/intolerance:


Anemia:


Wheezing, asthma, bronchitis:


Behavior problems/ADHD:


Eczema or skin problems:


High blood pressure:


Heart problems:


High Cholesterol:


Hepatitis or liver problems:


Bowel problems:


Diabetes:


Thyroid problems:


Kidney problems:


Depression / psychiatric:


Seizures:


Chicken pox:



Positive PPD/TB test:



FAMILY HISTORY:

Has anyone in the family ever had or been treated for the following? (Include the child's siblings, mother, father, grandparents, aunts and uncles.)

Allergies, sinus:


Food allergy/intolerance:


Anemia:


Wheezing, asthma, bronchitis:


Positive PPD/TB:


Eczema or skin problems:


High blood pressure:


Heart problems:


High Cholesterol:


Hepatitis or liver problems:


Bowel problems:


Diabetes:


Thyroid problems:


Kidney problems:


Depression / psychiatric:


Drug or alcohol problems:


Stroke:


Seizures:


Cancer: