Family History

Child’s name:   ____________________ 

 

Date of Birth:   ____________________

 

Today’s Date:      ____________________

 

We are interested in the medical histories of:

  • your child’s brothers and sisters
  • you and your spouse (or child’s biologic parent)
  • your brothers, sisters and parents

(The family histories of your cousins and grandparents is less relevant.)

 

 

Neurologic:

Seizures

Mental retardation

Learning disability/dyslexia

ADHD

Hearing problems

Migraines

 

Endocrine:

Thyroid disease

Diabetes - child onset

Diabetes - adult onset

Obesity

 

Allergic:

Asthma

Hay fever/Allergies

Food Allergies

Eczema

 

Cardiovascular:

Heart disease before age 60

High cholesterol

High blood pressure

 

Psychiatric:

Depression

Suicide

Drug/Alcohol abuse

Panic attacks

Eating disorder

ADHD

 


Other: