Personal Family History

							 Patient Name                                                   ____ DOB _____________ Date ______________

                                                 Personal / Family History for Child
    Please indicate which of the following have occurred in yourself or your family. Please use the following codes to
               indicate affected individuals. If more space is needed, please write at end of questionnaire.

                                                            S=Self (Patient)
                                   M=Mother                             GM = Grandmother
                                   F=Father                             GF = Grandfather
                                   B=Brother                            U = Uncle
                                   Si=Sister                            A = Aunt

     Medical Condition                No        Do         If Yes, code(s)         Comments; i.e. age at onset, specific diagnosis,
                                                Not                                             medications taken
                                               Know
Allergies - Environmental
Allergies - Food
Allergies - Medications
Eczema
Skin Disease(s)
Asthma/RAD
Cystic Fibrosis
Wheezing
Lung Disease (other)
Arthritis (joint problems)
Lupus (SLE)
Autoimmune disorders
Muscle disease
Bone deformities/brittle
bones/Scoliosis
Bleeding disorder
Anemia
Sickle Cell Anemia
Miscarriage/still birth
(indicate # and gestational age)
Diabetes
Thyroid disease
Endocrine disease (other)
Metabolic disease
Heart defects/murmur
Heart attack
High blood pressure
High cholesterol
Stroke
Seizure/Epilepsy
Migraines
Neurological disorder
Neuromuscular disorders
(eg myasthenia gravis, Lou
Gehrig’s (ALS)

Parkinson’s
Mental Retardation
Delayed Development




                                                                                                         Continued on back
                       S = Self                          GM = Grandmother
                       M=Mother                          GF = Grandfather
                       F=Father                          U = Uncle
                       B=Brother                         A = Aunt
                       Si=Sister
   Medical Condition         No     Do          If Yes, code(s)       Comments; i.e. age at onset, specific diagnosis,
                                    Not                                            medications taken
                                   Know
Substance abuse
Mental Illness / suicide
Vision/Hearing problems
Learning disability
Speech problems
Attention Deficit
Hyperactivity Disorder
(ADD/ADHD)
Autism
Psychiatric/ Emotional/
Behavioral problems
Kidney disease
Feeding/Eating disorders
Liver disease
Gastrointestinal/ stomach
problems
Cancer
Immunological disorder
Sinus Infections
Ear Infections
Strep Throat
Congenital defects
Down’s Syndrome
Weight Problems
Surgery (including ear
tubes)
                                                     Birth History
Gestational age at birth:                                        Days in nursery:
Birth Weight:                                                    Hospital of birth:
Birth Length:                                                    Vaginal or c-section delivery:
Health concerns as newborn: No                                   Labor or delivery complications: No
Infections during pregnancy: No                                  Oxygen requirement: No
Pregnancy complications: No                                      Infant feeding problems: No

                                                Developmental History
                               Age at which child first achieved the following milestones
Smiling                                                           Waving bye-bye
Rolling over completely                                           Walking
Sitting alone                                                     Riding a tricycle
Crawling                                                          Speaking in sentences
Saying first words                                                Any specific developmental delays or concerns



Signature                                                         Relation to patient


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