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)
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