Update to Child’s Health History 0 – 12 Years Child's Name* First Last Your Email* AgeSelect one< 12 Months123456789101112Appointment Date Date Format: MM slash DD slash YYYY Any new family health problems?Child care arrangements:Select oneHomeSitterDay CareOtherIf "Other", please explainAny changes at home, school, or daycare?Who lives in your home?New or Continuing ProblemsCheck any that applyGeneral 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 Date Format: MM slash DD slash YYYY 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 Date Format: MM slash DD slash YYYY 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 Behavior / Mental Health Depression Anxiety School Problems Fears Allergy symptomsList Medications (Prescription and Non-Prescription)Medication allergiesIs there tobacco use in child’s home?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 hours of TV per day?Please enter a number from 0 to 24.How often is car seat or seat belt used when riding in a car?Select oneNeverSometimes (25%)Usually (50%)Most of the time (75%)Always (100%)Describe eating patterns, number of meals per day, dietary problems:Please review your answers before submitting. Thank you!