Plymouth Family Physicians - HEALTH HISTORY FOR NEW PATIENTS (Birth to age 12)

Plymouth Family Physicians

HEALTH HISTORY FOR NEW PATIENTS (Birth to age 12)

The following will assist us in providing thorough care and in obtaining needed services for your infant or child.

Please complete the form below. Filling out this form electronically will be most efficient. If you prefer to use a Word document please send or bring the electronic file if possible. This form is also available in PDF format if you prefer to print it out and complete it manually.

PARENTS NEED TO BRING IMMUNIZATION RECORDS WITH THEM TO THIS VISIT!

Name (required)

E-mail

Birth Date

Age

PAST HEALTH HISTORY

Prenatal or newborn complications:

Any hospitalizations or surgeries:

CURRENT HEALTH INFORMATION

Please list any family health problems:

Father:

Mother:

Siblings:

Other Family:

Who lives with this child?

Medications (prescription or non-prescription)

Medication allergies

Tobacco use in the household? Yes No

Sleeping - Typical wake and sleep times

Discipline - How is this approached at home

Favorite Activities:

Number of hours of TV watched per day

How often is car seat or seatbelt used when riding in a car?

Describe eating patterns, number of meals per day, dietary problems:

NEW OR CONTINUING PROBLEMS (check any that apply):

GENERAL:

Fevers or chills
Weight change
Appetite change

EYES:

Vision concerns
Eye discharge or discomfort

If your child is over 3 years old, please provide the following:

Eye care provider:

Date of last exam?

EARS:

Change in hearing
Ear pain
Nasal congestion or bleeding

MOUTH:

Mouth sores
Sore throat
Dental problems

If your child is over 3 years old, please provide the following:

Dental provider:

Date of last exam?

Heart:

Chest pain
Heart concerns

Lungs:

Cough
Shortness of breath

BREASTS:

Pain
Nipple discharge
Masses

Bowels:

Abdominal pain
Change in bowels
Bleeding
Heartburn
Spitting up

Urinary:

Urinary problems
Menstrual problems

muscle/bone:

Injury to muscle or joint
Joint, muscle or back pain

brain, spine:

Speech or developmental concerns
Headaches

SKIN:

Rashes
Concerning lesions

Metabolism:

Unusual thirst
Weight loss

emotions:

Depression
Anxiety
School problems
Fears

ALLERGY:

Allergy symptoms

Any additional concerns you would like to address?

NOTE THAT AN ADDITIONAL APPOINTMENT MAY BE NEEDED TO ADEQUATELY MEET YOUR NEEDS.

I understand that the information on this page will be sent to Plymouth Family Physicians, S.C. and that this submission is not secure. If you are concerned, don't click the Submit button and PRINT THIS FORM or SAVE IT AS A FILE after completing it. You can then mail it or drop it off at the office. If you choose to complete this form at the office, please arrive at least 30 minutes before your appointment to complete all paperwork.