Medical History Form Online Please enable JavaScript in your browser to complete this form. - Step 1 of 6Patient Name *FirstMiddleLastBirth HistoryMaternal Age at Birth *Any Illnesses During Pregnancy? *YesNoMedication During Pregnancy? *YesNoAny of the Following During Pregnancy? *SmokingAlcoholIllegal DrugsNoneIn Which Hospital Did You Deliver? *What Was Your Child's Gestational Age at Birth? (e.g., term = 40 weeks) *Type of Delivery *VaginalCesareanAssisted Vaginal (e.g., with Forceps)NextBirth Weight *LengthApgar Scoreat 1 Minute and 5 MinutesRespiratory Problems? *Nasal CannulaCPAPIntubationOtherNoneJaundice? *YesNoAny Other Problems with Baby at Birth? *Pass Hearing Test? *YesNoDon't KnowWere You Ever Told Baby Was Breech in the 3rd Trimester? *YesNoPreviousNextDevelopmental HistoryPlease indicate age in months when milestone attained.WalkedRolled OverSat UpSmiledSpoke in SentencesPotty-TrainedCurrent Grade LevelPreviousNextPast Medical HistoryHospital AdmissionsDate and ReasonSurgeriesDate and ReasonChildhood IllnessesDate and IllnessList of MedicationsPrescription, Over-the-Counter, or Vitamins/SupplementsAllergiesFood, Drug, or EnvironmentalPreviousNextFamily Historye.g., Alcoholism, Blood Disorder, Epilepsy, Mental Illness, Tuberculosis, Asthma, Cancer, Heart Disease, Migraines, Sudden Death, High Blood Pressure, and AllergiesFatherMotherSiblingsPaternal GrandmotherPaternal GrandfatherMaternal GrandmotherMaternal GrandfatherPreviousNextSocial HistoryTeenage Drugs/Alcohol Usage *YesNoDon't KnowIs Patient Adopted? *YesNoDon't KnowTeenage Smoking *YesNoDon't KnowDoes Patient Go to Daycare? *YesNoDon't KnowDo Any Family Members Smoke? *YesNoDon't KnowTeenage Sexual Activity *YesNoDon't KnowAny Pets at Home? *YesNoDon't KnowNumber Living in Household *PreviousPhoneSubmit