SOCIAL HISTORY:

Parental
Sibling name(s) and age(s):
Who lives at home?
___________________________

Who is the primary caregiver or disciplinarian?
___________________________

Does the child attend school, daycare or a babysitter?
___________________________

Who helps the mother?
___________________________

Is violence at home a concern?
___________________________

Are there guns in the home?
___________________________

Do you have transportation to return if your child gets worse?
___________________________

Does anyone at home smoke or is the child exposed to smoke?
___________________________

Does any of your family members or caregiver smoke?
___________________________

Is your child in daycare?
___________________________

Are there any pets in the home?
___________________________

If yes, what type?
___________________________

Describe childcare outside of the home:
Name of child’s school and grade:
Child’s hobbies:

Family History Father Alive Deceased Age _____: list his pertinent health problems _____________________________ Mother Alive Deceased Age _____: list her pertinent health problems _____________________________ Number of Brothers _______Sisters: ______: list their pertinent health problems __________________________ (OVER) Social History Father/ guardian’s name: __________________________ relationship to child: ________________ Occupation: _______________________________ Contact numbers: work: _______________ home: _______________ other: _________________ Mother/ guardian’s name: __________________________ relationship to child: ________________ Occupation: _______________________________ Contact numbers: work: _______________ home: _______________ other: _________________ Child resides with: _________________________________________________________________ Child care (daycare, sitter, nanny, grandparents) ______________ hours/ week School name: _____________________________________ Grade: ____________________ Overall performance in school: Below grade level At grade level Above grade level Learning Disabilities: yes no Special Needs: yes no Gifted Program: yes no Hand dominance: right left TOBACCO EXPOSURE Smokers in the home: yes no SLEEP: Takes naps: yes no Sleeps with parents: yes no Sleeps through night: yes no Minimum 8 hours sleep each night: yes no Night mares/ sleep problems: yes no ACTIVITY: Exercise/ sports ________________ hours/ day TV/ computer games ____________ hours/ day SAFETY: uses bike/ skating helmet: yes no Car restraint (car seat, booster, seat belt): yes no Carbon Monoxide detector in home: yes no Smoke detector in home: yes no Radon in home: yes no untested tested THANK YOU --------------------------------------- 1 Patient: _______________________ DOB: ________ Pediatric < 18 (Please use pencil to complete this form.) FAMILY HISTORY 1.Is there any heart disease in your family history? Yes No Unknown If yes, circle the problem: High blood pressure, heart attack, high cholesterol, coronary artery bypass, stent placement. 2.Is there any diabetes in your family history? Yes No Unknown 3.Is there any cancer in your family history? Yes No Unknown If yes: what type of cancer(s)? ____________________ 4.Is there any osteoporosis in your family history? Yes No Unknown 5.Is there any asthma/emphysema in your family history? Yes No Unknown SOCIAL HISTORY 1.Do you use seatbelts/car seats? Yes No 2.Do you use ear protection when exposed to loud noises? Yes No 3.Are there any issues with violence or abuse in your life, past or present? Yes No 4.Do you follow good gun safety measures in your household? Yes No N/A 5.Do you use smoke detectors in your house? Yes No 6.Do you use CO detectors? Yes No N/A 7.Do you suffer from depression? Yes No 8.Does anyone in the house smoke cigarettes or cigars? Yes No 9.Do you follow a good diet with lots of fruits and vegetables and limited fat? Yes No 10.Do you currently have a weight problem? Yes No 11.Do you participate in any unique activities/challenges which are hazardous to your health? Yes No If yes, what? ____________________________ 12.Does anyone in the patient's household use alcohol? Yes No 13.Have you had an eye exam within the past two years? Yes No 14.Have you had a dental exam in the past year? Yes No 15.Have you had your hearing tested in the last two years? Yes No IMMUNIZATIONS Dtap: ____________ ____________ ____________ ____________ ____________ OPV/IPV: ____________ ____________ ____________ ____________ HIB: ____________ ____________ ____________ ____________ Hep B: ____________ ____________ ____________ MMR: ____________ ____________ Prevnar: ____________ ____________ ____________ ____________ DT: ____________ Varivax: ____________ Meningococcal: ____________ --------------------------------------- 2 Patient: _______________________ DOB: ________ Pediatric (Please use pencil to complete this form.) REVIEW OF SYSTEMS 1.Have you had any problems with your skin or moles that are changing? ___________________ _____________________________________________________________________________ 2.Have you had any bone, joint or muscle aches or pains? ________________________________ _____________________________________________________________________________ 3.Have you had any fatigue, weakness or bleeding disorders? _____________________________ ______________________________________________________________________________ 4.Have you had any vision changes, headaches or dizziness? ______________________________ ______________________________________________________________________________ 5.Have you had any problems involving your ears, nose or throat? __________________________ ______________________________________________________________________________ 6.Have you had any difficulty breathing, wheezing or respiratory problems? __________________ ______________________________________________________________________________ 7.Have you had any chest pain, palpitations, or other heart problems? _______________________ ______________________________________________________________________________ 8.Have you had any problems with your digestive system? ________________________________ ______________________________________________________________________________ 9.Have you had any problems urinating? ______________________________________________ ______________________________________________________________________________ 10.Are there any other health problems you have been having? _____________________________ ______________________________________________________________________________ UPDATED: ____________/_____________/_____________/______________/__________ ___________/_____________/_____________/______________/_____ This is a worksheet used for obtaining changing information to update the patients chart. It is not part of the patients legal record. 10/1/01ds --------------------------------------- 1 Pediatric Social History    PLEASE PRINT     Historian:       Aunt  Brother  Cousin  Father      Friend        Grandfather     Grandmother    Guardian       Mother       Nanny        Neighbor   Parent  Self      Sister    Stepbrother  Stepfather  Stepmother   Stepsister  Uncle    Patient’s Hand Dominance:    Right  Left    Resides with:  Lives alone   Mother  Grandmother  Aunt         Stepmother           Foster mother      Father    Grandfather   Uncle  Stepfather  Foster father     Adoptive mother   Adoptive father     Tobacco Exposure:   Smokers at home  Yes  No          Language Spoken at Home:  ____________________________________    Child care:  Provider   #Days/week      Mother   ____________      Father   ____________      Grandparent  ____________      Sibling   ____________      Nanny   ____________      Daycare   ____________      Sitter   ____________       Daycare Facility Name:  ____________________________________    Education:       School Name:  ___________________________________________  Grade: _________    Activity:        Exercise/sports  _______ hours per day  TV/computer games  _______ hours per day    Does patient have?   Turners” Syndrome      Down’s syndrome     Recent Travel:   Out of state   Out of country   Travel exposure