9006 S Fry Rd, Ste D, Katy, TX 77494
281-665-3013
832-913-8163
info@cincowestpediatrics.com

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Medical History Form

- Step 1 of 6

Patient Name *

First

Last

Date of Birth *//

Birth History

Maternal Age at Birth *

Any Illnesses During Pregnancy? *

Yes
No

Medication During Pregnancy? *

Yes
No

Any of the Following During Pregnancy? *

Smoking
Alcohol
Illegal Drugs
None

In Which Hospital Did You Deliver? *

What Was Your Child's Gestational Age at Birth (e.g., Term = 40 weeks)? *

Type of Delivery *

Vaginal
Cesarean
Assisted Vaginal (e.g., with Forceps)

Birth Weight *

Length

Apgar Score

at 1 Minute and 5 Minutes

Respiratory Problems? *

Nasal Cannula
CPAP
Intubation
Other
None

Jaundice? *

Yes
No

Any Other Problems with Baby at Birth?

Pass Hearing Test? *

Yes
No
Don't Know

Were You Ever Told Baby Was Breech in the Third Trimester? *

Yes
No

Developmental History

Indicate age in months when milestone attained

Smiled

Rolled Over

Sat Up

Walked

Spoke in Sentences

Potty-Trained

Current Grade Level

Past Medical History

Hospital Admissions

Date and Reason

Surgeries

Date and Reason

Childhood Illnesses

Date and Illness

List of Medications

Prescription, Over-the-Counter, or Vitamins/Supplements

Allergies

Food, Drug, or Environmental

Family History

e.g., Alcoholism, Blood Disorder, Epilepsy, Mental Illness, Tuberculosis, Asthma, Cancer, Heart Disease, Migraines, Sudden Death, High Blood Pressure, and Allergies

Father

Mother

Siblings

Paternal Grandmother

Paternal Grandfather

Maternal Grandmother

Maternal Grandfather

Social History

Teenage Drugs/Alcohol Use? *

Yes
No
Don't Know

Is Patient Adopted? *

Yes
No

Teenage Smoking? *

Yes
No
Don't Know

Does Patient Go to Daycare? *

Yes
No

Do Any Family Members Smoke? *

Yes
No

Teenage Sexual Activity? *

Yes
No
Don't Know

Any Pets at Home? *

Yes
No

Number Living in Household *

Message

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