Child’s Name: Date of Birth:

Contact Information for Parent 1

Name: Email:
Home Address:
Home Phone: Work Phone: Cell/Other:
Contact Information for Parent 2
Name: Email:
Home Address:
Home Phone: Work Phone: Cell/Other:
This child lives with: Mother Father Mother/Father Mother/Partner Father/Partner Grandparent/Other
MIT Affiliation
Person: Position: Department:

FAMILY HISTORY
1. Parent 1 Age: Current Health:
Past Health Problems:
Ethnicity: Education/Training:
2. Parent 2 Age: Current Health:
Past Health Problems:
Ethnicity: Education/Training:
3. Marital Status of Parents:
4. Other Children in Family:
Date of Birth Gender Name Healthy or Medical Issues?

5. Are there cultural or religious practices that might affect your child’s medical care? no yes
If yes, please explain (e.g. blood transfusion, dietary rules, etc.):

6. Is there tobacco use in/around your household? no yes

7. Is there a history in the family/a blood relative of:
If yes, state relationship to child
a. Allergies no yes
b. Anxiety no yes
c. Asthma no yes
d. Birth Defects/Genetic Problems no yes
e. Cancer
i. Brain no yes
ii. Breast no yes
iii. Colon no yes
iv. Ovarian no yes
v. Skin no yes
 vi. Thyroid no yes
vii. Other (describe and state relationship to child):
f. Depression no yes
If yes, state relationship to child
g. Diabetes no yes
h. Hearing Loss no yes
i. Heart Attack no yes
j. Heart Disease no yes
k. Hepatitis no yes
l. High Blood Pressure no yes
m. High Cholesterol no yes
n. Learning Disability no yes
o. Mental Illness no yes
p. Seizures no yes
q. Thyroid Problems no yes
r. Tuberculosis no yes

PRENATAL HISTORY
1. While pregnant, did mother have:
a. Bleeding or spotting no yes
b. German measles (Rubella) no yes
c. Gestational diabetes no yes
d. High blood pressure no yes
e. Illness other than cold/flu no yes
f. Kidney disease no yes
g. Premature labor no yes
h. Threatened miscarriage no yes
i. Toxemia no yes
2. Were medications or herbs taken during pregnancy? no yes
If yes, what kind:
3. Was a fertility treatment used for this pregnancy? no yes
If yes, what kind:

BIRTH HISTORY
1. Where was child born:
2. Was labor induced? no yes
3. Was labor helped by medication? no yes
4. Duration of labor:
5. Was child born early (less than 38 weeks)? no yes
6. Was child born late (after 42 weeks)? no yes
7. What was the method of delivery:
Breech
Caesarean (Please state reason):
Forceps
Spontaneous vaginal
8. Child’s birth weight:
9. Apgar Score (if known):
10. During the hospital stay, did child have any of the following:
a. Antibiotic treatment no yes
b. Blue spells no yes
c. Convulsions no yes
d. Jaundice no yes
e. Skin rash no yes
f. Did child remain in hospital longer than mother? no yes
11. How was/is baby
fed? Bottle
Breast
DEVELOPMENTAL HISTORY:
1. At what age did child: Age
a. Hold up head
b. Roll over
c. Sit unsupported
d. Stand alone
Age
e. Walk
f. Talk
g. Toilet train
h. Feed him/herself
i. Dress him/herself
IMMUNIZATIONS

PLEASE GIVE US A COPY OF PREVIOUS IMMUNIZATIONS/VACCINES

And TB (Tuberculosis) Testing or BCG Vaccination

Review of Systems:

Does your child have or has your child ever had significant issues with any of the following (if
yes, please explain):

Circle One If Yes, please explain

General:
Unexplained Fever Yes No
Poor weight gain/weight loss Yes No
Problems with nutrition Yes No
Difficulty feeding Yes No
Genetic disorders Yes No

Ear, Nose, and Throat

st
Recurrent Ear Infections Yes No Age at 1 infection
Number of ear infections in the past 6 months
Number of courses of antibiotics in past 6 months
Persistent middle ear fluid Yes No Duration present (months):
When last clear of middle ear fluid:
Concern with possible hearing loss Yes No
Concern that speech development
may not be age appropriate? Yes No
Balance disturbance Yes No
Nosebleeds Yes No
Nasal congestion Yes No
Recurrent Sinus infections Yes No
Number of sinus infections in past 12 months
Usual number of days with symptoms before starting antibiotics
Duration of antibiotics used to treat most infections
Recurrent tonsillitis Yes No Number of infections in past year
Number of episodes strep (+) tonsillitis:
in the past year ; the year before ; the year before that
Difficulty sleeping at night Yes No
Snoring Yes No
If yes: loud and obstructive Yes No
Retractions/working to breathe Yes No
Bedwetting Yes No
Mouth breathing during day Yes No
Excessive daytime tiredness Yes No
Hyperactivity Yes No
Difficulty chewing/ swallowing Yes No
Does food/liquid come out the nose when eating and/or drinking
Yes No

Eyes:
Wear Glasses Yes No Date of last exam
Infections/injuries Yes No
Other eye problems Yes No

Neurological:
Headaches Yes No
Seizure disorder Yes No
Developmental delay Yes No
Poor gross motor development Yes No
Cerebral palsy Yes No

Musculoskeletal:
Broken Bones Yes No
Developmental abnormalities Yes No

Respiratory:
Asthma/ reactive airway disease Yes No
Bronchopulmonary dysplasia Yes No
Noisy breathing Yes No
Shortness of breath Yes No
Cough Yes No
Bronchitis Yes No
Pneumonia Yes No

Allergic/Immunologic:
Environmental allergy symptoms Yes No
Perennial (year round) symptoms Yes No
Seasonal symptoms Yes No Which Season(s)

Food allergy symptoms Yes No

Immunologic disorder Yes No
Previous allergy testing Yes No At what age:
Allergist (Name/Practice/Location)
List any positive reactions:

Environment/food allergies– family member Yes No

Revised: 06/30/11 Page 3 of 6
Gastrointestinal:
Gastroesophageal reflux Yes No Age at diagnosis
Diagnostic tests used
Treatment given
Recurrent spitting up/ vomiting Yes No
Frequent reswallowing Yes No
Irritability after feedings Yes No
Chronic constipation Yes No
Recent change in Bowel Habits Yes No

Cardiovascular:
Congenital heart abnormality Yes No
Heart murmur Yes No

Bleeding Disorders:
Has your child ever had surgery, stitches for
trauma or a broken bone? Yes No
If yes, was there more bleeding than
expected during or after? Yes No
Does you child bruise more easily than normal Yes No
If a boy and circumcised, was bleeding more
than expected after the circumcision Yes No
Was there bleeding when the umbilical
cord came off? Yes No
Has your child had frequent nosebleeds? Yes No
Has your child bled more than normal
after loss of baby teeth? Yes No
Is your child taking aspirin or ibuprofen products? Yes No
If an older girl, is there a history of heavy
menstrual periods? Yes No
Has your child ever needed a blood transfusion
for prolonged bleeding? Yes No
Do any blood relatives have an inherited bleeding
problem such as Hemophilia, von Willebrand,
or low platelets? Yes No
Has any blood relative been called a free bleeder? Yes No

Hematologic/ Lymphatic
Anemia Yes No
Persistent Swollen Glands or Lymph Nodes Yes No
Blood Transfusion Yes No At what age
Reason

Genitourinary:
Urinary Tract Infections Yes No
Other abnormalities Yes No
Integumentary:
Eczema Yes No
Recurrent Rashes Yes No
Other skin abnormalities Yes No

Endocrine:
Diabetes Yes No
Thyroid abnormalities Yes No
Other hormonal abnormalities Yes No

Psychiatric
Depression Yes No
Attention Deficit Yes No
Behavioral Problem Yes No
Other psychiatric abnormalities Yes No

Family History

PAST MEDICAL HISTORY:

1. Has the child had:
a. Blood: anemia (iron deficiency, Sickle Cell, Thalessemia) no yes
b. Blood transfusions no yes
c. Chicken pox (Varicella) no yes
d. Contusions no yes
e. Convulsions no yes
f. Fractures no yes
g. German Measles (Rubella) no yes
h. Hospitalizations no yes
i. Measles (Rubeola) no yes
j. Meningitis no yes
k. Mumps no yes
l. Operations no yes
If yes, what illness?
m. Poison ingestion no yes
n. Other serious medical illnesses no yes
If yes, what kind?
o. Is your child currently taking any medications, vitamins or herbs? no yes
Medication Strength/Dose How Often?

p. Reaction to medication or food (allergy) no yes

If yes, please explain:

q. Any chronic or recurring pain? no yes

If yes, please explain:
2. Eyes:
a. Any visual problems? no yes
b. Do eyes look crossed? no yes
c. Does the child wear eyeglasses? no yes
3. Ears:
a. Any hearing problems? no yes
b. Three or more ear infections? no yes
 4. Nose:
a. Does the child have frequent attacks of sneezing or rubbing his/her nose? no yes
b. Has the child had frequent nose bleeds? no yes
5. Throat:
a. Does your child have three or more strep throat infections per year? no yes
6. Heart:
Have you ever been told your child has
a. A heart murmur? no yes
b. Heart defect? no yes
c. High blood pressure? no yes
7. Lungs:
Has your child ever had
a. Asthma/wheezing? no yes
b. Bronchitis or pneumonia? no yes
c. Chronic cough? no yes
8. Does your child tire easily? no yes
9. Abdomen
Has your child ever had
a. Blood in bowel movement? no yes
b. Difficulty with appetite or eating? no yes
c. Frequent abdominal pain? no yes
d. Frequent vomiting or diarrhea? no yes
e. Jaundice? no yes
f. Marked weight loss? no yes
If yes, please explain:
10. Kidney:
a. Does your child ever complain of burning or frequency of urination? no yes
b. Does your child wet the bed? no yes
c. Has there ever been blood in the urine? no yes
d. Has your child ever had a urinary tract infection? no yes
11. Skin:
a. Acne? no yes
b. Any sensitivity or allergy? no yes
c. Eczema or atopic dermatitis? no yes
12. Extremities:
Has your child
a. Had weakness or paralysis of arms or legs? no yes
b. A persistent limp? no yes
c. Every worn corrective shoes or braces? no yes
13. Neurological:
Has your child ever had
a. Breath holding? no yes
b. Convulsions or seizures? no yes
c. Dizziness? no yes
d. Fainting? no yes
e. Frequent headaches? no yes
f. Temper tantrums? no yes
14. Is your child:
a. Impulsive? no yes
b. Lacking in self-control? no yes
c. Overactive? no yes
d. Does your child have problems with:
i. Attending school? no yes
ii. Attention span? no yes
iii. Learning? no yes
iv. Mood? no yes

v. Parents? no yes
vi. Peers? no yes
vii. Siblings? no yes
 viii. Sleep? no yes
e. Are there concerns about physical, sexual or emotional abuse? no yes
(You may call Mental Health Services to set up an evaluation at 617.253.2916 for any of the above.)
15.Has your child begun puberty? no yes
16.Any other concerns you would like to discuss?

_____________________________________________ _____________________________________________
Parent Signature Date Provider Name Date Reviewed