Family History

PATIENT FAMILY HISTORY
Child's Name*
Child's Date of Birth*

MonthDayYear
Calculation
Newborn
Mother's Name*
Mother's Occupation*
Father's Name*
Father's Occupation*
List all siblings living in the home:*
No siblings
PRE-NATAL AND BIRTH HISTORY OF CHILD
Pregnancy:
Any illnesses or complications?

NoYes
Yes, please explain:*
Any smoking, alcohol, or recreational drug use during pregnancy?

NoYes
Yes, please explain:*
Delivery:
Any complications?

NoYes
Yes, please explain:*
Baby's:
Problems at or after birth:
Did your baby need any blood transfusions after birth?

NoYes
CHILD'S ALLERGIES TO
Medications (reaction date and symptoms):*
Foods:*
No allergies
PAST MEDICAL HISTORY OF CHILD
None
Hospitalizations or outpatient surgeries:
When*

MonthDayYear
Where*
Why*
When*

MonthDayYear
Where*
Why*
When*

MonthDayYear
Where*
Why*
Serious injuries:
When*

MonthDayYear
Where*
When*

MonthDayYear
Where*
When*

MonthDayYear
Where*
Previous MD / Clinic
Dentist
Fluoride

MedicationFluoridated WaterNone
Has a family member or contact with tuberculosis or a positive tuberculin skin test?*

NoYes
Was your child born in a country at high risk for tuberculosis? (Countries other than the United States, Canada, Australia, New Zealand or Western Europe)*

NoYes
Has your child traveled for longer than one week to a country at high risk for tuberculosis? (Countries other than the United States, Canada, Australia, New Zealand or Western Europe)*

NoYes

PATIENT FAMILY HISTORY CONTINUED
Your child's previous or current conditions (check all relevant)
None
Please list all previous or current conditions*

Recurrent ear infection (> 3)Recurrent throat infection (> 3)Allergies / Sinus problemsAsthma / WheezingEczemaConstipationChickenpoxScarlet FeverStomachachesHeadachesSeizuresEye problemsHearing problemsKidney / Bladder infectionsBlood transfusionsMental / Emotional problemsCigarette smokerDrug / Alcohol useTattoos / Body piercingOther
FAMILY HISTORY OF CHILD

Please indicate the child's blood relatives with the following problems using the abbreviations below:
M - Mother S - Sister MGM - Mother's Mother PGM - Father's Mother A - Aunt

C - Cousin F - Father B - Brother MGF - Mother's Father PGF - Father's Father

U - Uncle
No Significant History
AIDS*
Drug problems*
Migraine*
Allergies*
Eye problems*
Muscular disease*
Alcohol problem*
G.I. disease*
Neurological disease*
Anemia*
Hearing problems*
Seizure*
Asthma*
Heart attack (with age)*
Skin problems*
Arthritis*
Heart disease*
Sudden death (with age)*
Birth defects*
High blood pressure*
Thyroid disease*
Blindness*
High cholesterol*
Tobacco use*
Cancer (with type)*
Kidney disease*
Tuberculosis*
Cystic fibrosis*
Learning problems*
Peptic ulcer*
Deafness*
Mental illness*
Diabetes*
Mental retardation*
Other*
Are there pets in the home?*

NoYes
If yes, please list types:*
Are guns kept in the home?*

NoYes
If yes, are they securely locked away and inaccessible to children?*

YesNo
Are there additional issues not addressed above of which you would like to make JDC physicians aware?
Signature of individual completing form:*

Clear
Date*

MonthDayYear
Q
K
Should be Empty: