Health History

Canyon Pediatrics > Health History
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Patient Information

Patient Name
Have there recently been any major changes or stresses in your child’s life?
Does the child regularly go to a baby-sitter, pre-school, or day care?
Is your child exposed to cigarette smoke?
Is there a gun or weapon in the home?
Is there a pool on your property?
Are there any pets in the home?
Does your child use a car seat?
Does your child have any current legal involvement?
Has your child been seen by a dentist?
Have any Medical Problems:
Smoke or Drink:
Use any Medications:
Use Alcohol or Drugs:
Have Problems with Labor/Delivery:
Do you have any concerns about your child’s development?
Do you have any concerns with the following?
Regarding Immunization/Vaccines, is your child:

Canyon Pediatrics follows the vaccine recommendations of the American Academy of Pediatrics. This helps to ensure that when families visit our providers, they know the services and recommendations we set for others who visit.

If you do not feel that vaccinations are right for your family, Canyon Pediatrics may not be able to provide the services and recommendations you are looking for. If you have questions or would like to talk about modified schedules for the vaccines that will be recommended, we are happy to work with you to support your family’s health and comfort.

Have any of the child’s blood relatives had the following diseases:
Heart Disease:
Tuberculosis:
High Blood Pressure:
Kidney Disease:
Allergies/Asthma:
Cancer:
Diabetes:
Mental/Emotional Problems:
Blood Disorders:
Seizures:
Drug/Alcohol Problems:
High Cholesterol:
Stroke:
Autoimmune Disease:
Anxiety/Depression
Other:
Other:

Past Medical History

Is your child’s general health:
Does the child have any allergies?
Is the child taking any medications?

Please list any hospitalizations, operations, serious illnesses, or accidents:

Has your child had any problems with the following?

Eyes/Vision:
Skin:
Feet:
Lungs:
Digestion/Nutrition:
Teeth:
Ears/Hearing:
Heart:
Urine/Kidney:
Seizures
Infections:
Joints:

Is your child currently seeing any specialists: (Example: pulmonologist, behavioral health, nutritionist, etc…)

For adolescents

Is patient sexually active?
Have been or currently pregnant?
Currently using any form of birth control?
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