Medical History Form Please enable JavaScript in your browser to complete this form. - Step 1 of 6Patient Name *FirstLastDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Birth 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 Third Trimester? *YesNoPreviousNextDevelopmental HistoryIndicate age in months when milestone attainedSmiledRolled OverSat UpWalkedSpoke 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 Use? *YesNoDon't KnowIs Patient Adopted? *YesNoTeenage Smoking? *YesNoDon't KnowDoes Patient Go to Daycare? *YesNoDo Any Family Members Smoke? *YesNoTeenage Sexual Activity? *YesNoDon't KnowAny Pets at Home? *YesNoNumber Living in Household *PreviousMessageSubmit