Patient Health History(PEDIATRIC)

Last Name: First Name: Middle Initial:

Date of Birth:

Personal/Family Health History: Please check all areas that apply to the patient or their Mother or Father.

List any past surgical and hospitalization history:

Date Surgery/hospital stay

Page 1 of 1OPS Form 404 (Rev 00/00)

Indicate any history of: Patient

Mother

Father

Indicate any history of:

Patient

Mother

Father

ADD/ADHD Headaches/Migraines

Alcoholism Heart defectAnemia HIVArthritis Kidney (Renal)

diseaseAsthma Mental Health

ConcernsConcussion/Head injury PneumoniaDepression Seizure disorderDiabetes Staph infectionDrug abuse Thyroid diseaseEar infections Urinary Tract

Infection (UTI)Eczema Other:

Patient Health History(ADULT)

Name of medication Dosage How many times a day

Home Environment:Do you feel safe at home? Yes No Do you feel that your family has enough to eat? Yes No

Females Only:Ever had a menstrual period? Yes No If yes, age of first menstrual period?

Completed by: Date:

Page 1 of 1OPS Form 404 (Rev 00/00)

Patient Health History(ADULT)

Last Name: First Name: Middle Initial:

Date of Birth:

If you are taking medications please list them below:Name of medication Dosage How many times a day

Indicate any history of:

Yourself

Mother

Father

Indicate any history of:

Yourself

Mother

Father

ADD/ADHD GERD/HeartburnAlcoholism Headaches/

MigrainesAlzheimer’s Heart diseaseAnemia Hepatitis/Liver

diseaseAnxiety High cholesterolArthritis High blood pressure

(Hypertension)Asthma HIVBlood clots Mental

illness/disorderCancer ObesityCOPD OsteoporosisDepression Kidney (Renal)

DiseaseDiabetes Seizure disorderDrug abuse StrokeElevated lipids Thyroid diseaseGallbladder disease Other:

Personal/Family Health History: Please check all areas that apply to you or your Mother/Father.

List past surgical and hospitalization history:Date Surgery/Operation/Hospital

Do you drink alcohol? Yes No If you did drink alcohol in the past, when did you quit?

Page 1 of 1OPS Form 404 (Rev 00/00)

Patient Health History(ADULT)

Do you currently use any street drugs (including marijuana)? Yes No If yes, what kind?

Home Environment:Do you feel safe at home? Yes No

Completed by: Date:

Page 1 of 1OPS Form 404 (Rev 00/00)