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Patient Family History Form (All Ages)

PLEASE NOTE:
This form must be filled out completely. If a question does not apply, please mark "No" and/or fill in the field with "N/A". All questions are important for our office to better serve our patients.

Email Address:


Phone Number:


Child's Name:


Form Filled Out By:


Date Filled Out:


Patient lives with (please check one)?
mother and father
single parent family
divorced family

Parents live in what kind of setting (please check one)?
Rural      Urban      Suburban

Mother and/or father are working full-time?
Yes      No

If Yes, please describe who cares for the child during this time:


Mother's height is:     
Mother's age is:     
Mother's menstruation began at what age?   

Father's height is:     
Father's age is:     

Siblings in family (name/age/medical problems):


Family smoking history:


Pets in the home (please mark all that apply):
Dog      Cat      Iguana      Parakeet      Turtle     

Residence has (check one):
City      Well      Cistem

Has the child traveled outside of the U.S.?
Yes      No
If Yes, please describe timeframe and nature:


There has been a history of (please check all that apply):
Death      Major Moves      Divorce      Separation      Major Social Changes

Family history includes the following illnesses (please check all that apply):
Crohns disease     Ulcerative colitis     Irritable bowel syndrome     Hirschsprung Disease
Hiatal Hernia      Reflux      Heart Burn      Ulcers
Migraine      Fibromyagia / polymyalgia      Allergy to food      Allergy to drugs
Other Allergies      Asthma      Lactose Intolerance      Dysphagia
Constipation      Bleeding Diathesis      Colon Polyp      Cystic Fibrosis
Hepatitis A, B C      Wilsons Disease      Psychiatric Problems      Mental Retardation
Celiac Disease    Rheumatoid Arthritis    Systemic Lupus Erythematosus    Short Stature
Thyroid Problem      Failure to Thrive      Growth Delay      Gastrointestinal Surgery
GI Bleeding      Gall Stones      Kidney Stones      Portal Hypertension
Any Transplant      Seizures      Autism      ADHD
Depression or Bipolar Disorder      Genetic Diseases      Anemia      Others not listed     

Thank you for taking the time to fill out this form, we do appreciate your efforts. Your child's health is important to us, your answers will help us serve your child's needs better.