Health Literacy Universal Precautions Toolkit, 2nd Edition

Young Child Health History Form

[Microsoft Word file Microsoft Word version - 76 KB]

Child's Name

_________________________________________________________  

_________________________________________________________  

_________________________________________________________  

Today's Date: ___________________________________

Date of Birth: ___________________________________  

Child's Address

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

_________________________________________________________________________________________________________  

Filling out this form

  • Answering these questions will help your doctor understand your child's health and how best to treat your child.
  • If you need help filling out this form:
    • Bring this form with you to your appointment and a nurse will help you.

      OR

    • Call the clinic at [555-1212 ext. 123] before your appointment and someone can help you over the phone.

Bring to your appointment:

  1. This Child Health History Form and any other important medical records.
Icon: a pen fills out a form.
  1. A complete copy of the child's  Immunization (shot) records.
Icon: Immunization records.
  1. The child's insurance information.
Icon: a hand holds an insurance card.
  1. Any medicines the child takes (prescription, herbal, over-the-counter pills and creams).
Icon: medication bottles, pill-cards, and tubes.

We look forward to working with you!


General Information

What is the child's sex?    ___ Female   ___  Male  

Child's Date of Birth______________________ current age ___________________________________

Is your child adopted?  ___ No      ___ Yes    If yes, at what age? ___________________________________

Who is filling out this form?

___ Mother

___ Father

___ Other guardian (please explain relationship to child): ________________________

___ Other (please explain): ______________________________________________________________________

The child's parents are:  

___ Single    ___ Married    ___ Divorced    ___ Separated but not divorced

___ Widowed    ___ Living together but not married    ___ Unknown

Main adult contact for child Other adult contact for child
Name: ________________________ Name: ________________________
Relation to child:
___ Mother   ___ Father
___ Other: ________________________
Relation to child:
___ Mother   ___ Father
___ Other: ________________________
Address: ___ Same as child's
Street address: ____________________
________________________
City: ________________________
State: _____________________
Zip: ____________________
Address: ___ Same as child's
Street address: ____________________
________________________
City: ________________________
State: _____________________
Zip: ____________________
Home Phone: Home Phone:
Cell Phone: Cell Phone:
Work Phone: Work Phone:

Today's Health Problems

1. List your child's main health problems (or reasons for visiting the clinic).

___  Routine checkup

___  Immunizations (shots)

___  A health problem (please specify): __________________________________________________________________________________________________)

___  Switching doctors (last doctor): __________________________________________________________________________________________________)

2. How well do you feel your child acts or behaves?

___ Poor    ___ Fair    ___ Good    ___ Very Good   ___ Excellent

Medical History

3. Has your child ever been a patient in a hospital (other than a few days after birth)?  

___ No (If no, go to question #4.)

___ Yes (If yes, explain why and when below.)  

My child was in the hospital because: When
Example: Bike accident 5 years old
   
   
   
   

4. Is your child taking any prescription medicines?

___ Yes—Please list the child's medicines below or   ___ I brought my child's medicines. 

___ No. My child does not take any prescription medicines. (If no, go to question #5.)  

Name of medicine Amount / size of pill How many pills or doses do you take at
Example: Dexadrine 10 mg  1  morning   ___ noon   ___ dinner    1  bed
    ___ morning   ___ noon   ___ dinner   ___ bed
    ___ morning   ___ noon   ___ dinner   ___ bed
    ___ morning   ___ noon   ___ dinner   ___ bed
    ___ morning   ___ noon   ___ dinner   ___ bed
    ___ morning   ___ noon   ___ dinner   ___ bed
    ___ morning   ___ noon   ___ dinner   ___ bed

(Please use the back of this form if you have more prescription medicines.)

5. What over-the-counter medicines, does your child take regularly?

___ Vitamins  

___ Herbal medicine (please list) ________________________________________________________________________

___ Other (please list) __________________________________________________________________________________

___ None, my child does not take any over-the-counter medicines regularly.

6. Does your child have any allergic reaction (bad effects) from any of the following? (Check all that apply.)

___ Outside or Indoor allergies (for example: grass, pollen, cats …)

___ Food Allergies (for example: peanuts, milk, wheat …)

___ Medicine or shots (immunization). (Please list below.)

___ No, my child has no allergies that I know of.

Medicine child is allergic to What happens when I take that medicine
Example: Amoxicillin Diarrhea (runny poop)
   
   
   

7. Has your child had any of the following diseases?

Measles ___ Yes ___ No ___ Don't Know
Mumps ___ Yes ___ No ___ Don't Know
Chicken Pox ___ Yes ___ No ___ Don't Know
Whooping Cough ___ Yes ___ No ___ Don't Know
Rubella ___ Yes ___ No ___ Don't Know
Rheumatic Fever ___ Yes ___ No ___ Don't Know
Scarlet Fever ___ Yes ___ No ___ Don't Know

8. Please check any of the following medical problems that your child has ever had.

Has your child ever had:  
Ear infections ___ Yes   ___ No
Nose problems (sinus infections, nose bleeds) ___ Yes   ___ No
Eye problems (blurry vision, need to wear glasses) ___ Yes   ___ No
Hearing problems ___ Yes   ___ No
Mouth or throat problems (Strep throat, swallowing problems) ___ Yes   ___ No
Diarrhea (having frequent and runny bowel movements/poop) ___ Yes   ___ No
Constipation (problems having a bowel movement /poop) ___ Yes   ___ No
Problems peeing (bed wetting, pain when peeing) ___ Yes   ___ No
Back problems (crooked back, back pain) ___ Yes   ___ No
Growing pains (bone or body pains due to growing) ___ Yes   ___ No
Muscle and bone problems (weak muscles, pain in joints) ___ Yes   ___ No
Skin problems (acne, flaking skin, rashes, hives) ___ Yes   ___ No
Seizures (shaking fits) ___ Yes   ___ No
ADD/ADHD (problems paying attention, sitting still) ___ Yes   ___ No
Sleeping problems (falling or staying asleep) ___ Yes   ___ No
Breathing problems (cough, asthma) ___ Yes   ___ No
Warts ___ Yes   ___ No
Jaundice (yellow skin) ___ Yes   ___ No

Shots

9. Has your child received immunizations (shots) in the past?

___ No (If no, go to question #10.)

___ Yes

If yes, have you given this office a copy of the immunization (shots) records?

___ Yes (If no, go to question #10.)

___ No

If not, please give us the name of the doctors' offices or clinics where your child has received these shots so we can get the records.

     Doctor's office/clinic name: ____________________________________________________________

     Doctor's office/clinic phone number: ____________________________________________________________

About Mom When Pregnant

The following questions are about the mother of the child during pregnancy and birth.

If you do not know about the pregnancy of the mother, check here ___  and go to #17.

10. What was the general health of the mother during pregnancy?

___ Excellent     ___ Good     ___ Fair     ___ Poor     ___ Unknown

11. Were any of the following used during pregnancy?

___ Cigarettes

___ Alcohol

___ Illegal drugs (which ones?  ___________________________________________)

___ Prescription drugs (which ones? ______________________________________)

___ None of the above

12. Did the mother have any of the following conditions or problems during pregnancy?

___ Preeclampsia (high blood pressure)

___ Diabetes (sugar)

___ Emotional stress

___ Injury or serious illness

___ Unexpected bleeding or spotting

___ Other ____________________________________________________________  

13. Was the birth:

___ On the due date

___ Before the due date (by how much ____________________________________________________________)

___ After the due date (by how much ____________________________________________________________

14. Was the birth: ___ Vaginal     ___ C-Section (surgical cut in the tummy?)

15. Were any of the following used?

___ Pain medicine during birth (epidural)

___ Tool to help pull baby out (forceps or vacuum)

___ None

16. Were there any problems during the birth?    ___ Yes    ___ No

If yes, please explain:

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

About the Child As a Baby

17. Was/is the child breastfed?    ___ Yes    ___ No

If yes, how long ____________________________________________________________

18. In the first 2 months after birth, did the child have:

___ Jaundice (yellow skin)

___ Colic (upset stomach, crying)

___ Breathing problems

___ Other ____________________________________

___ None of the above

19. At what age did the child begin to crawl? ____________________________________

20. At what age did the child begin to sit up? ____________________________________

21. At what age did the child begin to walk? ____________________________________

22. At what age did the child get his/her first tooth? ____________________________________

23. At what age did the child began to say words (mama, dada)? ____________________________________

24. How would you rate your child's health in his or her first year of life?

___ Excellent   ___ Very Good   ___  Good   ___ Fair   ___ Poor   ___ Unknown

In School and At Home

25. Does the child go to school or daycare?   ___ Yes   ___  No

If yes, what is its name? 

________________________________________________________________________

26. If your child goes to school or daycare, describe how your child acts in school or daycare.

Check all that apply.

___ Nervous, worried

___ Shy, withdrawn, keeps to self

___ Hyper, restless, can't sit still

___ Gets angry easily

___ Pushy, bullies others

___ Scared, fearful

___ Relaxed, calm

___ Moody

___ Social, friendly

___ Happy

27. How are your child's grades in school?

___ Excellent   ___ OK   ___ Poor   ___ Does not go to school

28. About how much exercise does your child get every day?

___ Less than 30 minutes   ___ 30 minutes to 1 hour   ___ Over 1 hour

29. About how many hours of TV does your child watch every day?

___ Less than1 hour   ___ 1-3 hours   ___ More than 3 hours

30. About how many hours is your child on a computer every day?

___ Less than 1 hour   ___ 1-3 hours   ___ More than 3 hours   ___ Does not have a computer

31. About how many hours does your child spend outside every day?

___ Less than1 hour   ___ 1-3 hours    ___ More than 3 hours

32. About how many hours are spent reading with your child every day?

___ Less than 15 minutes   ___ 15-30 minutes   ___ 30 minutes to1 hour&  ___ More than 1 hour

33. Does your child wear a helmet when riding a bike, roller blading, skate boarding, etc.?

___ Yes   ___ No   ___ Does not do activities like that

34. Does your child get buckled in a car seat or wear a seat belt when riding in a car?

___ Yes   ___ No

35. Do you have guns in the home?   ___ Yes   ___ No

If yes, are they locked up?   ___ Yes   ___  No

36. What activities is your child involved in:

___ Riding bike

___ T-ball/baseball

___ Dance/movement

___ Skate boarding

___ Karate

___ Video games

___ Girl Scouts/Boy Scouts

___ Soccer

___ Playing a musical instrument

___ Reading

___ Playing with friends

Other team sports ____________________________________

___ Other activity(s) ____________________________________

___ Too young to be involved in activities

37. Please list what your child typically eats and drinks in a day for:

Breakfast:

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

Lunch:

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

Dinner:

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

Snacks:

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

Family

38. Check all the people that the child lives with:

___ Mother

___ Father

___ Brothers (how many? _________________)

___ Sisters (how many? _________________) 

___ Other family members (list):

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

___ Friends or other people (list):

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

___ Animals ___    Dogs (how many?_________________    ___ Cats (how many?_________________

___ Other animals):

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

39. What medical problems do people in the child's family have?

Family Member Medical Problems
Mother: ___ Depression   ___ Anxiety (nerve) problems
___ Learning disability   ___ Overweight
___ High blood pressure   ___ Diabetes (sugar)
___ Cancer   ___ Heart problems___
Other: __________________________________________
Father: ___ Depression   ___ Anxiety (nerve) problems
___ Learning disability   ___ Overweight
___ High blood pressure   ___ Diabetes (sugar)
___ Cancer   ___ Heart problems___
Other: __________________________________________
Sisters: ___ Depression   ___ Anxiety (nerve) problems
___ Learning disability   ___ Overweight
___ High blood pressure   ___ Diabetes (sugar)
___ Cancer   ___ Heart problems___
Other: __________________________________________
Brothers: ___ Depression   ___ Anxiety (nerve) problems
___ Learning disability   ___ Overweight
___ High blood pressure   ___ Diabetes (sugar)
___ Cancer   ___ Heart problems___
Other: __________________________________________

Return to Contents

Page last reviewed February 2015
Page originally created February 2015
Internet Citation: Young Child Health History Form. Content last reviewed February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool11b.html