Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Pediatric Medical History Form
Your information
Child's Name
Date of Birth
____ / ____ / ________
Parent / Guardian Name
Parent / Guardian Phone
Gestational Age at Birth
Delivery Method
- Vaginal delivery
- Cesarean delivery
- Not sure
Birth Weight
NICU Admission
Breastfeeding / Formula History
Additional details
Developmental Milestones Met On Time
Developmental Concerns
Childhood Illnesses
Chronic Conditions
Current Medications
| Medication | Dose | How often |
|---|---|---|
Known Allergies
| Allergy | Reaction |
|---|---|
Immunization Status
Additional Notes
Parent / Guardian Signature
Date
Pediatric Medical History Form template from formisoft.com. formisoft.com/intake-templates/pediatric-medical-history