TenderCare Pediatrics Initial History
Visit Date _______Patient Name____________________Birth date____
A. PRENATAL HISTORY:
1. Was your baby born on time? Yes No
2. What was the birth weight? ________
3. Was your baby a vaginal delivery? Yes No
4. Breastfed? Yes No
Formula type if used ____________________
5. Did your baby have any trouble while in
the hospital? (Jaundice, Infections,
other?) ______________________
B. PAST MEDICAL HISTORY
1. Allergies to medication? No Yes
Please list ____________________________
2. Medications? No Yes
Please list ____________________________
3. Hospitalizations? No Yes
Please list reason/s _____________________
4. Surgeries? No Yes
Please list ____________________________
_____________________________________
5. Persistent/Chronic Illness? None Yes
Please list _____________________________
_____________________________________
6. Are immunizations up to date? Yes No
Please provide a certificate of previous shots.
C. FAMILY HISTORY:
1. Does your child's parent, grandparent,
brother or sister have
any of the following? No Yes
If yes, please circle the problem
in whom. Diabetes_____, Anemia _____,
Epilepsy/Seizures_____, Mental Ill _____,
Congenital malformations_____, TB_____,
Asthma/Allergies_____,
Cancer & type_____,
High blood pressure_____,
Heart attacks/Heart disease_____,
Other_____
SIGNATURE ___________________RELATIONSHIP __________DATE _____
