Health History for New Patient: Birth – 12 Years Child's Name* First Last Your Email* Child's Date of Birth AgeSelect one< 12 Months123456789101112Past Health HistoryPrenatal or newborn complicationsAny hospitalizations or surgeriesPlease list the name of each family member and any health concerns: Father, Mother, Siblings, Other FamilyWho lives with this child?Child care arrangements:Select oneHomeSitterDay CareOtherIf "Other", please explainMedications (Prescription and Non-Prescription)Medication AllergiesIs there any tobacco use in the household?YesNoTypical bed time : HH MM AM PM Typical time of wake : HH MM AM PM Discipline - How is this approached at home?Favorite ActivitiesHow many screen hours of TV / computer/video games per day?Please enter a value between 0 and 24.How often is a car seat or seat belt used when riding in a car?NeverSometimes (25%)Usually (50%)Most of the time (75%)Always (100%)Describe eating patterns, number of meals per day, dietary problems:New or Continuing Problems(Check all that apply today)General Symptoms Fevers or Chills Weight change Appetite change Eyes Vision Concerns Eye discharge or discomfort If your child is three years or older, please provide their eye care provider:Date of last vision exam Ears Change in hearing Ear pain Nasal congestion or bleeding Mouth Mouth sores Sore throat Dental problems If your child is three years or older, please provide their dental care provider:Date of last dental exam Heart Chest pain Heart concerns Lungs Cough Shortness of breath Breasts Pain Nipple discharge Masses Bowel Abdominal Pain Change in bowels Bleeding Heartburn Spitting up Urinary Urinary problems Menstrual problems Muscle / Bone Injuries 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 SymptomsAny additional concerns you would like to address?Note that an additional appointment may be needed to adequately meet your child's health needs.Please review your answers before submitting. Thank you!