New Patient History Form

Welcome to Lighthouse Pediatrics! We are pleased that you have chosen to establish your child in this special practice. In order for us to use your time with the doctor wisely, could you please take a few moments to complete the following information about your child?

Name of Child:

Date of Birth:

Does your child have any ongoing medical problems?:
YesNo

If yes, please list

Specialist(s), if any:

Does your child have any past medical problems which he/she's outgrown?:
YesNo

Has your child spent the night in the hospital?
YesNo

Any surgeries?
YesNo

Please list with approximate date(s):

Is your child on medications (include prescription and over-the-counter)?
YesNo

If yes, please list along with doses:

Pharmacy:

Does your child have any allergies?
YesNo

Please list:

Please choose any of the conditions that run in your family (parents, aunts/uncles, grandparents and siblings) and what family member is affected.

ADD/ADHD
Allergies
Arthritis
Asthma
Cancer
Cardiac Disease
Crohn's oor Ulcerative Colitis

Diabetes
Drug/Alcohol Abuse
High blood pressure
High cholesterol
Migraines
Prolonged QT syndrome
Seizure

Sickle cell
Sudden Unexplained death
Thyroid Disorders
Vision/Hearing disorders
Other

Who lives in the house with your child?

Do you own any pets?
YesNo

If yes, type of pet:

Are there any smokers in the home?
YesNo InsideOutside

Do you have any water near your home?
YesNo

If yes, please choose
Private PoolCommunity PoolLakeCanalOcean

If you have a private pool, do you have a pool fence?
YesNo

If your child is 4 years or older, does he/she know how to swim?
YesNo

Does you child attend a daycare or school?
YesNo

Name of the daycare or school:

Grade/year:

Does your child have any special needs in school or daycare?
YesNo

If so, please list:

Do you have any questions/concerns you want to address today?

Do you have any prayer requests?