Obtaining the Initial History at the First Visit

A worksheet follows which will allow you to obtain the child and family's medical and social history at the first visit for a child of any age. A print version is available on the sidebar.

Child and Family Medical History

Current Health Status

Gestation History

1. Gravida:_____Para:_____Abortions:_____
2. Prenatal care Yes or No? Number of visits _____
3. Length of gestation ______ weeks
4. Maternal age at patient's birth__________
5. Smoking? Yes or No? packs/day______
6. Alcohol? Yes or No? Amnt/Freq_____
7. Drugs (recreation) Yes or No? Name/Freq______

8. Maternal medications / drugs used during pregnancy
9. Maternal problems during pregnancy:
__anemia __hospitalization __syphilis
__cardiac disease __hypertension __U.T.I.
__diabetes __Rh negative __vaginal bleeding
__gonorrhea __rubella __hepatitis
__herpes __seizures


Birth & Nursery Course

12. Place of Birth:_____________________________________________
13. Problems during labor and delivery? (eg. Induction, postpartum hemorrhage)_______
14. Type of delivery: spontaneous, forceps C-Section. Length of labor:_____ hours
15. Infant's condition at birth: _______________APGAR: 1 min:_____5 min:_______
16. High risk nursery? Yes No Length of time:______
17. Birth weight: Length Head Circumference: Small/large for gest age
18. Problems:
__birth defects __convulsions __meningitis/sepsis
__blood transfusions __feeding problems __oxygen or respirator used
__congenital infections __jaundice __other


Past Medical History


Exposures: lead, pesticides, smoke

Allergies - "...drug, food, other."


Family Medical History



___alcoholism, drug addition

___kidney disease


___mental illness







___hearing problems



___other disorders

____drug/alcohol abuse

___heart diseases

Current Health Status of




Medications taken regularly



Developmental History



Diet History

Diet: see age specific worksheet

Social History

Who lives at home? Who cares for the baby? Any new changes or stressors at home? Any indoor or outdoor cigarette smoke exposure? Pets? Firearms? Child safety and concern for child abuse?


Quickchecks on the Initial History and First Visit

 Quiz Group