Past Medical History Social History

Medical Information

If checked yes, please CIRCLE all conditions that apply

  Unexplained weight gain or loss?

  Recent fever (above 100)

  Eczema, itching, rashes, or large birth marks?

  Eye surgery, glasses, or contact lens?

  Recurrent infection, congestion, or discharge in or from the ears/nose/throat/mouth?

  Heart murmurs, shortness of breath, high blood pressure?

  Asthma, chest pain, recurrent cough?

  Feeding problems, diarrhea, constipation, vomiting?

  Kidney or bladder infection, pain with urination, inability to control urine?

  Other joint pains, fractures?

  Seizures, head trauma, delayed age for walking or talking, attention deficit disorders, learning issues at school?

  Depression, behavioral problems, addiction?

  Any known problems with thyroid, growth hormone, diabetes?

  Bleeding problems, easy bruising, frequent nose bleeds, low blood count, sickle cell disease?

  Recurrent unexplained arm or leg swelling, bumps or knots under the arm or in the groin

  Environmental allergies, food allergies, sensitivity to costume jewelry or balloons?
If over Age 14 Menstrual History

Do you drink alcohol? Yes No (Females over age 10)

Do you use tobacco? Yes No Have you started your periods? Yes No

(smoking or chewing) If yes, how long ago?

When was you last period?