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CHILD MEDICAL HISTORY FORM (0-12 MONTHS).

Please ensure you have completed a Patient Contact Details Form prior to completing this Medical History Form for your Child.

Nameyour full name
Date of Birthdd/mm/yy
What is your child's main problem?
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When did it start?
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What do you consider caused this problem?
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Has this problem occurred before and if so when?
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At the onset of the problem, did your child experience any trauma, illness/infection or other significant event?
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Are your child's symptoms worse at night or any specific time of day?
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What relieves your child's problems?
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What makes your child's problems worse?
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Has your child had any other treatment for the current problems?
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If so, what was the diagnosis?
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Who was the practitioner?optional
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Did you find the treatment effective?
Please rate the severity of your child's symptoms10 being the most severe pain (drag button)
1
010
Has your child had any form of surgery or hospitalisation?If yes, please detail
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Is your child currently taking any form of medication?If yes, please list medications.
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Does your child have any other illness, past or present?If yes, please detail
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Has your child had any broken bones, accidents or significant injuries?No matter how trivial please describe details
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Child's siblingsPlease list name, age, sex and relationship to the child (Full/ Half Adopted/ Step)
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Do any of the siblings have medical problems?
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How many pregnancies have you had?Please include any miscarriages and still births
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Pregnancy:
YesNo
Did you smoke during your pregnancy?
Did you drink alcohol during your pregnancy?
Did you take any medication during your pregnancy?
Abdominal Injury
Fever and/or rash
Diabetes
Morning Sickness
Vaginal Bleeding
Toxemia, Eclampsia, Preeclampsia
Surgery
High Blood Pressure
Rh incompatibility
Did you have any of the following complications during your pregnancy?
YesNo
Abdominal Injury
Fever and/or rash
Diabetes
Morning Sickness
Vaginal Bleeding
Toxemia, Eclampsia, Preeclampsia
Surgery
High Blood Pressure
Rh incompatibility
Were there any other complications?
0 /
Were there any abnormalities on ultrasound during your pregnancy?If yes please comment
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Was amniocentesis performed?If yes, what were the results
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What was your baby's gestational age at birth?Weeks
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Where was your baby born?
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Was labour spontaneous or induced?
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Please detail length of each stage of labourStage 1 & Stage 2
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Did you have any medications during your labour?
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Were there any complications during your child's birth?
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Please comment on at the assistance used during birthForceps/vacuum extraction/caesarian section/episiotomy
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Baby's birth weight
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Baby's birth length
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APGAR ScoreAt 1 minute
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APGAR ScoreAt 5 minutes
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How many days after birth did you take the baby home?
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Birth:
YesNo
Did you baby have bruises?
Did your baby have birthmarks?
Did your baby have any breathing problems?
Did your baby cry quickly?
Was the cord wrapped around your baby's neck?
Did you baby have jaundice?
Was your baby placed in an incubator/or in ICU?
Did your baby have seizures or convulsions?
Was your baby placed on a breathing machine?
Was fluid stained with your baby's meconium (bowel movement)?
Was your baby considered to be limp?
Was your baby considered to be stiff?
Did your baby have feeding or sucking problems?
Health & Development:
YesNo
More than two episodes of otitis media (ear infection)
Ventilatory (myringotomy) tubes (grommets)
Visual difficulty
Movement problems
Poisoning or drug overdose
Sleep problems
Hearing difficulty
Failure to thrive
Convulsions/seizures/epilepsy
Poor growth or weight gain
Do you have any other concerns about your baby?
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I consent for information about my child to be communicated to my GP and/or other relevant health professionals where appropriate
Nameyour full name
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