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LOUDOUN COUNTY HEALTH DEPARTMENT CHILD HEALTH HISTORY Please complete—this will help us to better care for your child. A. BIRTH HISTORY 1. Maternity care: Place___________Date 2. Was this pregnancy yes ( ) no ( ) 3. Full ( ) no ( ) 4. Delivered Vaginal ( ) c-section ( ) 5. Problems at delivery? Mother no ( ) yes ( ) baby no ( ) yes ( ) Type of 6. Tobacco, alcohol, drugs during pregnancy? no ( ) yes ( ) C. FEEDING AND NUTRITION 1. Is your child’s appetite usually good? yes ( ) no ( ) 2. Any colic, spitting, feeding problems? no ( ) yes ( ) 3. Check: breast ( ) bottle ( ) type of 4. Does your child eat things that are not food? no ( ) yes ( ) B. PAST MEDICAL HISTORY 1. Where has your child gone for 2. Date of last visit to Dentist:_________ 3. Allergy to: medicines ( ) food ( ) bug bites ( ) 4. Any reactions to shots? no ( ) yes ( ) 5. Any hospitalizations, accidents, injuries? no ( ) yes ( ) 6. Is child taking medicines? no ( ) yes ( ) What? (include D. DEVELOPMENT AND BEHAVIOR 1. At what age did your child sit 2. At what age did your child walk 3. Did your child say words by 18 months? yes ( ) no ( ) 4. At what age was your child toilet 5. Does your child wet the bed? no ( ) yes ( ) 6. Does your child have trouble sleeping? no ( ) yes ( ) 7. Does your child play well with others? yes ( ) no ( ) 8. Has your child repeated a grade in school? no ( ) yes ( ) E. SAFETY AND ENVIRONMENT 1. Where does the family live? house ( ) apartment ( ) trailer ( ) other ( 2. How many people live in the home? Languages spoken at 3. Who takes care of the child most of the time? parent ( ) relative ( ) babysitter ( ) daycare ( ) other ( 4. Is there a working smoke detector on each floor? yes ( ) no ( ) 5. Does anyone in the household smoke? no ( ) yes ( ) 6. What type of drinking water does the home have? county/city ( ) well ( ) bottled ( ) 7. Have you ever suspected your child has been mistreated? no ( ) yes ( ) 8. Are there guns in the home? no ( ) yes ( ) F. FAMILY AND CHILD MEDICAL HISTORY Check any health problems for child, child’s parents, grandparents, brothers, sisters, aunts, and uncles. Child Family Child Family Office Use Only 1.Allergies 14.Hepatitis/Liver disease 2.Anemia-Low blood iron 15.High blood pressure 3.Asthma/Bronchitis/Pneumonia 16.HIV/AIDS 4.Birth defects/Retardation 17.Learning problems/ADHD 5.Bladder/Kidney problems 18.Mental illness/Suicide 6.Cancer 19.Muscle/Joint/Bone pain 7.Dental problems 20.Sexually transmitted diseases 8.Diabetes (sugar) 21.Skin problems 9.Diarrhea/Constipation 22.Sore throat/Frequent colds 10.Drug/Alcohol/Tobacco use 23.Thalassemia/Sickle cell 11.Ear problems/Tubes/Deafness 24.Tuberculosis 12. Epilepsy/Seizures 25.Vision/Eye problems 13.Heart problems/Murmurs DATE REVIEWED: INITIALS: LABEL: