Patient Name
Date of Birth
Sex M F
Form Completed By:
Today's Date
Relationship
Name of Hospital
Illnesses during pregnancy? Yes No
Medication during pregnancy? Yes No
Alcohol/Drug Abuse? Yes No
Problems at birth? Yes No
Describe
Type of delivery? Vaginal C-section
Birth Weight
Discharge Weight
Did baby receive Hepatitis B vaccine? Yes No
Date of Hepatitis B immunization
Newborn Hearing Screen? Yes No
Who lives in household?
How many?
Rent? Own? Shelter?
Who cares for child?
Date of Birth?
Mother Father
Foster Care?
Dates
Other Languages?
Has anyone in the family (parents, grand-parents, aunts/uncles, sisters/brothers) had:
Who?
Allergies Yes No
Allergies (List)
Asthma Yes No
TB/Lung Disease Yes No
HIV/AIDS Yes No
Suicide Attempts Yes No
Heart Disease Yes No
High Blood Pressure/Stroke Yes No
High Cholesterol Yes No
Blood Disorders/Sickle Cell Yes No
Diabetes Yes No
Seizures Yes No
Mental Illness Yes No
Cancer Yes No
Birth Defects Yes No
Hearing Loss Yes No
Speech Problems Yes No
Kidney Disease Yes No
Alcohol/Drug Abuse Yes No
Hepatitis/Liver Disease Yes No
Tyroid Disease Yes No
Learning Problems/Attention Yes No
Deficit Disorder Yes No
Family Violence Yes No
Other
Has your child ever had:
Chicken Pox (Year) Yes No
Frequent Ear Infections Yes No
Vision/Hearing Problems Yes No
Skin Problems/Eczema Yes No
Seizures/Epilepsy Yes No
High Blood Yes No
Heart Defects/Desease Yes No
Liver Disease/Hepatitis Yes No
Kidney Disease/Bladder Infections Yes No
Physical or Learning Disabilities Yes No
Bleeding Disorders/Hemophilia Yes No
Sexualy Transmitted Diseases Yes No
Emotional or Behavioral Problems Yes No
Depression/Suicidal Thoughts Yes No
Hospitalizations/Surgeries Yes No
Physical/Emotional/Sexual Abuse Yes No
Bone or Joint Injuries Yes No
Obesity/Eating Disorders Yes No
845-B Quince Orchard Blvd, Gaithersburg, MD 20878
(301) 977-2440