Pediatric Medical History Form

Pediatric patients have unique medical history needs that differ significantly from adult intake forms. This form is purpose-built to capture the health information most relevant to children and adolescents, starting with birth history including gestational age, delivery method, birth weight, and NICU admission. Parents and guardians can document their child's developmental milestones, feeding history, and any early childhood concerns that have been flagged by prior providers.

The form covers common childhood illnesses, recurrent conditions such as ear infections or asthma episodes, and any chronic diagnoses the child is managing. A dedicated section for growth and development allows parents to report known delays in speech, motor skills, or social development. Vaccination history is also addressed, though practices may pair this form with a dedicated immunization record for comprehensive tracking.

Designed for pediatricians, family medicine providers, and pediatric specialists, this form ensures that clinicians have the full developmental and medical context they need from the very first visit. It supports digital completion by parents or guardians before the appointment, allowing providers to focus in-person time on examination and counseling rather than data collection.