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New Patient Medical History

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					                                                                                Douglas R. Coombs MD, FAAP
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                                                                                520 East Medical Drive Suite 301
                                                                                Bountiful, Utah 84010
Birth History: Birth Hospital:                                                  (810) 292-1464

Weight:             Length:               Birth date:

Delivery Type (Circle all that apply):                            Name_________________________________________
         Vaginal         C-Section
         Full Term        Premature_____wks                     ALLERGIES: _________________________________________
                                                                ____________________________________________________
Blood Type – Mother:      Baby:   Coombs:                       ____________________________________________________
Feedings (circle): Breast     Formula                           ____________________________________________________
                                                                ____________________________________________________
Hepatitis Shot (circle):           Yes         No               ____________________________________________________
Complications:                                                  ____________________________________________________

Childhood History:                                              Date      Problems                          Resolved
Medications:                                                    ____________________________________________________
                                                                ____________________________________________________
Allergies to medications/foods/environment?                     ____________________________________________________
                                                                ____________________________________________________
Surgeries:                                                      ____________________________________________________
                                                                ____________________________________________________
Other Hospitalizations:                                         ____________________________________________________
                                                                ____________________________________________________
Childhood Diseases (circle):                                    ____________________________________________________
 Chicken Pox     Asthma      RSV                        Croup   ____________________________________________________
                                                                ____________________________________________________
Other:                                                          ____________________________________________________
Immunization (circle): Current Behind Not Sure                  ____________________________________________________
                                                                ____________________________________________________
Medical Problems:                                               ____________________________________________________
                                                                ____________________________________________________
                                                                ____________________________________________________
Family Medical History:                                         ____________________________________________________
(Check if any family member has any of the following)           ____________________________________________________
                          This                   Other          ____________________________________________________
                         Child Parents Siblings Relative
Allergies/Hay Fever       ___   ___      ___     ___            ____________________________________________________
Asthma/Wheezing           ___   ___      ___     ___            ____________________________________________________
Eczema                    ___   ___      ___     ___            ____________________________________________________
Frequent Headaches        ___   ___      ___     ___            ____________________________________________________
Frequent Ear Infections ___     ___      ___     ___
Eye Problems              ___   ___      ___     ___            ____________________________________________________
Heart Murmur              ___   ___      ___     ___            ____________________________________________________
Heart Disease             ___   ___      ___     ___            ____________________________________________________
High Cholesterol          ___   ___      ___     ___            ____________________________________________________
High Blood Pressure       ___   ___      ___     ___
Urinary Tract Infections ___    ___      ___     ___            ____________________________________________________
Diabetes                  ___   ___      ___     ___            ____________________________________________________
TB/Positive Skin Test     ___   ___      ___     ___            ____________________________________________________
Hearing Problems          ___   ___      ___     ___            ____________________________________________________
Birth Defects             ___   ___      ___     ___
Seizures/Convulsions      ___   ___      ___     ___            ____________________________________________________
Learning Problems         ___   ___      ___     ___            ____________________________________________________
Mental Illness            ___   ___      ___     ___            ____________________________________________________
Anemia                    ___   ___      ___     ___            ____________________________________________________
Bedwetting                ___   ___      ___     ___
Bleeding Disorder         ___   ___      ___     ___            ____________________________________________________
Cancer                    ___   ___      ___     ___            ____________________________________________________
Medication Reactions      ___   ___      ___     ___            ____________________________________________________

				
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posted:6/3/2010
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