PEDIATRIC HEALTH HISTORY FORM

Dr. Chris Cooke
503-719-6556
drclcooke@comcast.net
www.drchriscooke.com

By completely filling out this form you will help us to help you.  All answers will be absolutely confidential.  If you have any questions please ask.  Thank you.

Name
 Today’s Date _

Age
Date of birth
Home address 

City 
Zip Code ________________
Home telephone
Work/cell:   # 
Email address: (optional)

Please put an “X”  before any item you wish to mark.
Gender:
M 
F
Who referred you to our clinic? 

Parent/ Guardian Information

Mother’s Name 
Work Phone: 
Occupation: 
Employer: 
Father’s Name
Work Phone: 
Occupation: 
Employer:

Guardian’s Name 
Work Phone: 

Names of Healthcare Providers:
Medical Doctor(s) 

Naturopathic Physician
Chiropractor 
Other  

School Grade
School Name______________________________________________

Siblings Name(s)/Age(s) 
Child’s Main Health Concerns	
 Please list the reasons for your visit and when the concerns began:

1.

2.

3.

4.

5.

Does your child have a contagious disease at this time? 
No
Yes
If yes, what? 

Mother’s Pregnancy   
Please put an X before any that apply.
 Uncomplicated 
 Early Labor  
 Excessive vomiting 
 Bleeding  
 Physical or emotional trauma	
 Diabetes
 Thyroid problems 
 High blood pressure 
 Smoking, alcohol or drug use
Medications during pregnancy:  None   Vitamins
   Other (name)__________________________________ 	

Birth History 
Birth weight (lbs) 
Weeks gestation 
 Vaginal
C-section
Reason for C- section 

Mother's age at child's birth? 

Birth complications or interventions used? Describe: _	

Post-natal Complications
Please put an X before any that apply.
None
Jaundice
Respiratory 	 
 Cardiac
Infections
Gastrointestinal 
 Birth defects
Birth injuries

Developmental History  
Rolled over at 
Sat at
Crawled at
Was child breastfed? 
No
Yes, if so how long? 
Difficulty nursing?
No
Yes
Formula used?  No
Yes
When were solids begun?
Colic?   
No
Yes

Immunizations	
Check immunizations given and put an X before    the last age given in the series. 
 HIB                2mo           4mo             6mo             18mo 
 DPT                2mo           4mo             6mo             18mo           4-6yrs           14-16yrs
 Polio               2mo           4mo             6mo             18mo           4-6yrs
 Hep B        birth-2mo    1-4mo        6-18mo          9-13yrs
 Varicella       12mo
 Polio               2mo           4mo        6-18mo            4-6yrs
 Pneumococcal  2mo         4mo              6mo        12-15mo
 Meningococcal  2mo        4mo              6mo             12mo       14-16yrs
 MMR            12mo        18 mo           4-6yrs
 Influenza     6-23mo

Any reactions to immunizations? Describe: __________________________________	

Height 
Weight lbs

Medical History:  Put an “X before  all  current or past conditions	

General
 Easy bleeding/bruising
Excessive fatigue
 Fainting/ Dizziness                                       
 Heat/cold intolerance
High fevers
 Itching Night sweats
Motion/ car sickness
Body/breath odor                                          
 Frequent urination
 Anemia
 Heart murmur                                                
                     
Skin
 Rashes
Eczema
Acne
 Hives

Head/ Eyes/ Ears/ Nose / Throat
 Tooth/ mouth pain
 Mercury amalgam fillings
Sinus problems
 Head injuries
Headaches
Eye pain or blurry vision
Nose bleeds
 Meningitis/ Encephalitis 
Ear infections
Sore throats  
 Tonsillitis 

Respiratory
 Bronchitis
Chronic cough
Pneumonia
 Asthma
 Wheezing

Digestion
 Constipation
Diarrhea
Nausea/Vomiting                                                                                  
 Poor appetite
Excessive thirst or hunger
 Stomach aches
 Belching/ gas
Reflux

Brain/Nervous system
 Anxiety
Seizures/ Epilepsy
Depression                                                                                                                                                   
Suicidal thoughts
 Autism spectrum
 ADHD

Musculoskeletal
 Joint pain
Muscle spasms/cramps
Broken bones/fractures                                                                               
             
Infections/Immune system
 Measles
Rubella
Chicken pox
Mumps   
 Diptheria
Strep infections
Frequent colds/flus
Scarlet fever                               
 Urinary tract infections               Whooping cough                     Rheumatic fever
  Hayfever

Behavior

Excellent
Variable
Disruptive

Is there a concern with or history of (Put an X by any that apply):
 Biting
Bed Wetting
Hitting
Head banging 
 Aggressiveness
Odd fascinations
Stuttering
Teeth grinding 
 Pulling own hair
Hyperactivity
Breath-holding
Cries easily
Mood swings
Irritability
Difficulty concentrating
Excessive spinning
Hand flapping
Tics  

Sensitivity or aversion to:
Sound
Touch
Smells
Lights
Food textures
Clothing tags/textures

Play skills:
Appropriate
Inappropriate

Sleep:
Frequent waking
Nightmares
Bedtime
Number of hours of sleep 

Hospitalizations/ Surgeries / Injuries:  Please list with dates.
___

Is there anything else you would like to mention in order that I may know your  child better?