New General Pediatric Patient History- Ages Newborn To Five Years New General Pediatric Patient History- Ages Newborn To Five Years New General Pediatric Patient History- Ages Newborn To Five Years Demographics Child's First Name * Child's Last Name * Child's Street Address * Child's City * Child's State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Child's Zip Code Child's Birthdate * Child's Sex * Female Male Child's Age In Months (click here) Child's Age In Years (click here) Parent Or Other Primary Caretaker Name * Parent Or Other Primary Caretaker Name First First Last Last Parent Or Other Primary Caretaker Address * Parent Or Other Primary Caretaker Address Parent Or Other Primary Caretaker Address Parent Or Other Primary Caretaker Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Parent Or Other Primary Caretaker Phone * Parent Or Other Primary Caretaker Email * Parent Or Other Primary Caretaker Relationship To Child * Parent Or Step-Parent Grandparent Sister Or Brother Other Family Member Foster Parent Legally Appointed Guardian Other Birth History How Was The Child Born? * Normal Spontaneous Vaginal Delivery Elective Caesarian Section Emergency Caesarian Section Other At How Many Weeks Of Gestation Was The Child Born? * What Was The Child's Birthweight In Pounds And Ounces? * What Was The Child's One Minute Apgar Score? Enter "Unknown" If You Don't Know It. * What Was The Child's Five Minute Apgar Score? Enter "Unknown" If You Don't Know It. * Where There Multiple Births? * One Child Only Twins Triplets Other Were there any complications of the child's birth? Past Medical History List Any Hospitalizations, Including The Child's Age And Reason For Hospitalization. Enter "None" if none. * List Any Surgical Procedures Requiring Anesthesia, Including The Child's Age And The Type Of Surgical Procedure. Enter "None" if none. * List All Of The Child's Prescription Medications (enter "None" if none) * Review Of Systems Has the child had problems with the eyes or vision? (enter "None" if none)* * Has the child had problems with ears and ear infection, if so, how many? (enter "None" if none) Has the child had problems with chronic or recurrent sore throat, if so, how many? (enter "None" if none) Has the child had any heart issues, such as heart murmur or abnormal heart rhythm? (enter "None" if none) * Has the child had problems with chronic cough, asthma, or pneumonia? (enter "None" if none) List All Of The Child's Allergies (enter "None" if none) * Has the child had any stomach, bowel, or digestive issues? (enter "None" if none * Has the child had any neurological issues, such as seizures or developmental delay? (enter "None" if none) * Has the child had urinary or kidney infections or stones or other problems? (enter "None" if none) * Has the child had any orthopedic (bone) problems? (enter "None" if none) * Has the child had any skin issues, such as eczema? (enter "None" if none) * Has the child had any other issues not covered above? (enter "None" if none) * Immunization History-List All Immunizations The Child Has Had How Many Doses Of Hepatitis B Vaccine Has The Child Had? (Check all that apply) 1st Dose (usually at the time of birth 2nd dose (usually at 1-2 months of age) 3rd dose (usually at 6 to 15 months of age) None Don't know How Many Doses Of RSV (Respiratory Syncytial Virus) Vaccine Has The Child Had? (Check all that apply) 1st Dose (usually at some time between birth and six months of age) 2nd dose (usually at 8-19 months of age) None Don't know How Many Doses Of DTaP (diphtheria, tetanus, acellular pertussis) Vaccine Has The Child Had? (Check all that apply) * 1st Dose (usually at 2 months of age) 2nd dose (usually at 4 months of age) 3rd dose (usually at 6 months of age) 4th dose (usually at 15 months of age) 5th dose (usually at 4-6 years of age) None Don't know How Many Doses Of Tdap (diphtheria, tetanus, acellular pertussis) Vaccine Has The Child Had? (Check all that apply) * 1st Dose (usually at 11-12 years age) None Don't know How Many Doses Of Rotavirus Vaccine Has The Child Had? (Check all that apply) * 1st Dose (usually at 2 months of age) 2nd dose (usually at 4 months of age) 3rd dose (usually at 6 months of age) None Don't know How Many Doses Of HiB (hemophilus influenza type b) Vaccine Has The Child Had? (Check all that apply) * 1st dose (usually given at 2 months of age) 2nd dose (usually given at 4 months of age) 3rd dose (sometimes given at 6-15 months of age) 4th dose (sometimes given at 12-15 months of age) None Don't know How Many Doses Of Pneumococcal Vaccine Has The Child Had? (Check all that apply) * 1st dose (usually given at 2 months of age) 2nd dose (usually given at 4 months of age) 3rd dose (usually given at 6 months of age) 4th dose (usually given at 12-15 months of age) None Don't know How Many Doses Of Inactivated Polio Vaccine Has The Child Had? (Check all that apply) * 1st dose (usually given at 2 months of age) 2nd dose (usually given at 4 months of age) 3rd dose (usually given at 6-18 months of age) 4th dose (usually given at 4-6 years of age) None Don't know How Many Doses Of Measles, Mumps, Rubella Vaccine Has The Child Had? (Check all that apply) * 1st dose (usually given at 12-15 months of age) 2nd dose (usually given at 4-6 years of age) None Don't know How Many Doses Of Varicella (chickenpox) Vaccine Has The Child Had? (Check all that apply) * 1st dose (usually given at 12-15 months of age) 2nd dose (usually given at 4-6 years of age) None Don't know How Many Doses Of Hepatitis A Vaccine Has The Child Had? (Check all that apply) * 1st dose (usually given at 12-15 months of age) 2nd dose (usually given at 12-24 months of age) None Don't know Development Assessment Social/Emotional Milestones-Two Months Of Age * Calms down when spoken to or picked up Looks at your face Smiles when you talk to or smile at her Language/Communication Milestones-Two Months Of Age * Makes sounds other than crying Reacts to loud sounds Cognitive Milestones (learning, thinking, problem-solving)-Two Months Of Age * Watches you as you move Looks at a toy for several seconds Movement/Physical Development Milestones-Two Months Of Age Holds head up when on tummy Moves both arms and both legs Opens hands briefly Social/Emotional Milestones-Four Months Of Age * Smiles on his own to get your attention Chuckles (not yet a full laugh) when you try to make him laugh Looks at you, moves, or makes sounds to get or keep your attention Language/Communication Milestones-Four Months Of Age * Makes sounds like “oooo”, “aahh” (cooing) Makes sounds back when you talk to him Turns head towards the sound of your voice Cognitive Milestones (learning, thinking, problem-solving)-Four Months Of Age * If hungry, opens mouth when he sees breast or bottle Looks at her hands with interest Movement/Physical Development Milestones-Four Months Of Age Holds head steady without support when you are holding him Holds a toy when you put it in his hand Uses his arm to swing at toys Brings hands to mouth Pushes up onto elbows/forearms when on tummy Social/Emotional Milestones-Six Months Of Age * Knows familiar people Likes to look at self in a mirror Laughs Language/Communication Milestones-Six Months Of Age * Takes turns making sounds with you Blows “raspberries” (sticks tongue out and blows) Makes squealing noises Cognitive Milestones (learning, thinking, problem-solving)-Six Months Of Age * Puts things in her mouth to explore them Reaches to grab a toy she wants Closes lips to show she doesn’t want more food Movement/Physical Development Milestones-Six Months Of Age Rolls from tummy to back Pushes up with straight arms when on tummy Leans on hands to support herself when sitting Social/Emotional Milestones-Nine Months Of Age * Is shy, clingy, or fearful around strangers Shows several facial expressions, like happy, sad, angry, and surprised Looks when you call her name Reacts when you leave (looks, reaches for you, or cries) Smiles or laughs when you play peek-a-boo Language/Communication Milestones-Nine Months Of Age * Makes a lot of different sounds like “mamamama” and “bababababa” Lifts arms up to be picked up Cognitive Milestones (learning, thinking, problem-solving)-Nine Months Of Age * Looks for objects when dropped out of sight (like his spoon or toy) Bangs two things together Movement/Physical Development Milestones-Nine Months Of Age Gets to a sitting position by herself Moves things from one hand to her other hand Uses fingers to “rake” food towards himself Sits without support Social/Emotional Milestones-Twelve Months Of Age * Plays games with you, like pat-a-cake Language/Communication Milestones-Twelve Months Of Age * Waves “bye-bye” Calls a parent “mama” or “dada” or another special name Understands “no” (pauses briefly or stops when you say it) Cognitive Milestones (learning, thinking, problem-solving)-Twelve Months Of Age * Puts something in a container, like a block in a cup Looks for things he sees you hide, like a toy under a blanket Movement/Physical Development Milestones-Twelve Months Of Age Pulls up to stand Walks, holding on to furniture Drinks from a cup without a lid, as you hold it Picks things up between thumb and pointer finger, like small bits of food Social/Emotional Milestones-Fifteen Months Of Age * Copies other children while playing, like taking toys out of a container when another child does Shows you an object she likes Claps when excited Hugs stuffed doll or other toy Shows you affection (hugs, cuddles, or kisses you) Language/Communication Milestones-Fifteen Months Of Age * Tries to say one or two words besides “mama” or “dada,” like “ba” for ball or “da” for dog Looks at a familiar object when you name it Follows directions given with both a gesture and words. For example, he gives you a toy when you hold out your hand and say, “Give me the toy.” Points to ask for something or to get help Cognitive Milestones (learning, thinking, problem-solving)-Fifteen Months Of Age * Tries to use things the right way, like a phone, cup, or book Stacks at least two small objects, like blocks Movement/Physical Development Milestones-Fifteen Months Of Age Uses fingers to feed herself some food Social/Emotional Milestones-Eighteen Months Of Age * Moves away from you, but looks to make sure you are close by Points to show you something interesting Puts hands out for you to wash them Looks at a few pages in a book with you Helps you dress him by pushing arm through sleeve or lifting up foot Language/Communication Milestones-Eighteen Months Of Age * Tries to say three or more words besides “mama” or “dada” Follows one-step directions without any gestures, like giving you the toy when you say, “Give it to me." Cognitive Milestones (learning, thinking, problem-solving)-Eighteen Months Of Age * Copies you doing chores, like sweeping with a broom Plays with toys in a simple way, like pushing a toy car Movement/Physical Development Milestones-Eighteen Months Of Age Walks without holding on to anyone or anything Scribbles Drinks from a cup without a lid and may spill sometimes Feeds himself with his fingers Tries to use a spoon Climbs on and off a couch or chair without help Social/Emotional Milestones-Twenty-four Months Of Age * Notices when others are hurt or upset, like pausing or looking sad when someone is crying Looks at your face to see how to react in a new situation Language/Communication Milestones-Twenty-four Months Of Age * Points to things in a book when you ask, like “Where is the bear?” Says at least two words together, like “More milk.” Points to at least two body parts when you ask him to show you Uses more gestures than just waving and pointing, like blowing a kiss or nodding yes Cognitive Milestones (learning, thinking, problem-solving)-Twenty-four Months Of Age * Holds something in one hand while using the other hand; for example, holding a container and taking the lid off Tries to use switches, knobs, or buttons on a toy Plays with more than one toy at the same time, like putting toy food on a toy plate Movement/Physical Development Milestones-Twenty-four Months Of Age Kicks a ball Runs Walks (not climbs) up a few stairs with or without help Eats with a spoon Social/Emotional Milestones-Thirty Months Of Age * Plays next to other children and sometimes plays with them Shows you what she can do by saying, “Look at me!” Follows simple routines when told, like helping to pick up toys when you say, “It’s clean-up time.” Language/Communication Milestones-Thirty Months Of Age * Says about 50 words Says two or more words together, with one action word, like “Doggie run” Names things in a book when you point and ask, “What is this?” Says words like “I,” “me,” or “we” Cognitive Milestones (learning, thinking, problem-solving)-Thirty Months Of Age * Uses things to pretend, like feeding a block to a doll as if it were food Shows simple problem-solving skills, like standing on a small stool to reach something Follows two-step instructions like “Put the toy down and close the door.” Shows he knows at least one color, like pointing to a red crayon when you ask, “Which one is red?” Movement/Physical Development Milestones-Thirty Months Of Age Uses hands to twist things, like turning doorknobs or unscrewing lids Takes some clothes off by himself, like loose pants or an open jacket Jumps off the ground with both feet Turns book pages, one at a time, when you read to her Social/Emotional Milestones-Three Years Of Age * Calms down within 10 minutes after you leave her, like at a childcare drop off Notices other children and joins them to play Language/Communication Milestones-Three Years Of Age * Talks with you in conversation using at least two back-and-forth exchanges Asks “who,” “what,” “where,” or “why” questions, like “Where is mommy/daddy?” Says what action is happening in a picture or book when asked, like “running,” “eating,” or “playing” Says first name, when asked Talks well enough for others to understand, most of the time Cognitive Milestones (learning, thinking, problem-solving)-Three Years Of Age * Draws a circle, when you show him how Avoids touching hot objects, like a stove, when you warn her Movement/Physical Development Milestones-Three Years Of Age Strings items together, like large beads or macaroni Puts on some clothes by himself, like loose pants or a jacket Uses a fork Social/Emotional Milestones-Four Years Of Age * Pretends to be something else during play (teacher, superhero, dog) Asks to go play with children if none are around, like “Can I play with Alex?” Avoids danger, like not jumping from tall heights at the playground Likes to be a “helper” Changes behavior based on where she is (place of worship, library, playground) Language/Communication Milestones-Four Years Of Age * Says sentences with four or more words Says some words from a song, story, or nursery rhyme Talks about at least one thing that happened during her day, like “I played soccer.” Answers simple questions like “What is a coat for?” or “What is a crayon for?” Cognitive Milestones (learning, thinking, problem-solving)-Four Years Of Age * Names a few colors of items Tells what comes next in a well-known story Draws a person with three or more body parts Movement/Physical Development Milestones-Four Years Of Age Catches a large ball most of the time Serves herself food or pours water, with adult supervision Unbuttons some buttons Holds crayon or pencil between fingers and thumb (not a fist) Social/Emotional Milestones-Five Years Of Age * Follows rules or takes turns when playing games with other children Sings, dances, or acts for you Does simple chores at home, like matching socks or clearing the table after eating Language/Communication Milestones-Five Years Of Age * Tells a story she heard or made up with at least two events. For example, a cat was stuck in a tree and a firefighter saved it Answers simple questions about a book or story after you read or tell it to him Keeps a conversation going with more than three back-and-forth exchanges Uses or recognizes simple rhymes (bat-cat, ball-tall) Cognitive Milestones (learning, thinking, problem-solving)-Five Years Of Age * Counts to 10 Names some numbers between 1 and 5 when you point to them Uses words about time, like “yesterday,” “tomorrow,” “morning,” or “night” Pays attention for 5 to 10 minutes during activities. For example, during story time or making arts and crafts (screen time does not count) Writes some letters in her name Names some letters when you point to them Movement/Physical Development Milestones-Five Years Of Age Buttons some buttons Hops on one foot Dietary History What Foods Does The Child Take Each Day? Check All That Apply. * Breastmilk Cow's milk-based infant formula Soy-based infant formula Infant cereals Infant fruits Whole milk Low-fat milk Skim milk Protein (meat, fish) Breads, Cereals Fruits Green/yellow vegetables Other If The Child Is One Year Old Or Less And Taking Infant Formula, How Many Ounces Per Day Does The Infant Take Per Day On Average? Does the child seems overweight or underweight to you? * Underweight Overweight Neither underweight or overweight Does The Child Take Any Dietary Or Nutritional Supplements? Are There Any Foods The Child Does Not Tolerate, Such As Milk Or Wheat? * Do You Have Any Dietary Or Activity Questions Or Concerns? Enter "None" If You Have No Such Concerns. * Family History Does The Child Have Any Living Siblings (brothers or sisters)? Yes No Please Briefly Describe The Child's Living Siblings By Age, Sex, And Any Health Issues Does The Child Have Any Deceased Siblings (brothers or sisters)? Yes No Please Briefly Describe The Child's Deceased Siblings By Age, Sex, And Principal Cause Of Death Please Briefly Describe The Ages And Health Of The Child's Parents * Please Briefly Describe The Ages And Health Of The Child's Grandparents Or, If Deceased, Their Ages At The Time Of Death And The Principal Cause Of Death * Social History Does The Child Live With Both Natural Parents? Yes No Is Either Parent Deceased? No Mother is deceased Father is deceased Who Has Legal Custody Of The Child? Check all that apply? Both Parents Living Together With The Child Mother Not Living With The Father Father Not Living With The Mother Step-mother Step-father Other Family Member Unrelated Person(s) Please Briefly Describe The Child's Living/Custody Arrangements Who Is/Are The Child’s Primary Caretakers? Check All That Apply. At home mother Mother working outside the home full-time Mother working outside the home part-time At home father Father working outside the home full-time Father working outside the home part-time Other family member part-time Other family member full-time Non-family member full-time Non-family member part-time Is The Child's Father Currently Employed? Employed outside the home Employed at home Employed, working both at home and outside the home Not employed at this time Briefly, What Kind Of Work Does The Child's Father Usually Do For Employment When Employed? Is The Child's Mother Currently Employed? Employed outside the home Employed at home Employed, working both at home and outside the home Not employed at this time Briefly, What Kind Of Work Does The Child's Mother Usually Do For Employment When Employed? Child Care Attended * Licensed Day Care Center-full time Licensed Day Care Center-part time Informal Play Group In Home Babysitter Licensed Pre-School Or Nursery School Kindergarten School Other Child Care Cared For Only By Family Members In The Home Does The Child Receive Any Special Education Services? * No Yes Please Describe The Special Education Services The Child Receives. Are There Any Diseases That Seem To Run In The Family? If Not, Enter "None" * Safety History Does The Child Ride In An Approved Car Seat When Traveling By Car? * Yes, always Yes, sometimes Not usually Never Does The Child Wear A Helmet When Riding A Bicycle? * Yes, always Yes, sometimes Not usually Never Does Not Ride A Bicycle If The Child Is An Infant Less Than Eight Months Old, Is The Infant Electronically Monitored While Sleeping? * Yes, always Yes, sometimes Not usually Never Does The Home Have All Required Smoke And Carbon Monoxide Detectors Installed? * Yes No If There Are Any Firearms Or Ammunition In The Home, Are They Properly Secured? * No firearms or ammunition in the home Firearms or ammunition present but secured Firearms or ammunition present, not secured Do You Have Any Concerns That The Child Is Being Physically, Emotionally, Or Sexually Abused By Anyone? * No Yes Possibly Do You Have Any Other Comments Or Questions Or Is There Anything Else That You Wish To Mention? 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