Medical History Form

5757 Monclova Road Suite 10, Maumee OH 43537

Phone: 419-887-0803

Fax: 419-887-0817

Medical History Form

Please complete all fields as accurately as possible.

Patient Information

Patient's Last Name

Patient's First Name

Date of Birth

Today's Date

Birth History

Gestational Age at Birth (weeks)

Birth Weight

Birth Length

Any complications during pregnancy?

Yes No

If yes, describe

Any complications during delivery?

Yes No

If yes, describe

Was the baby in the NICU?

Yes No

If yes, how long?

Developmental History

Any concerns with speech or language development?

Yes No

Any concerns with motor development (walking, coordination)?

Yes No

Any concerns with social or behavioral development?

Yes No

Describe any developmental concerns in detail

Has the child received Early Intervention or therapy services?

Yes No

If yes, type of therapy and dates

Previous Medical History

Previous Pediatrician / Provider

Phone

Reason for Leaving Previous Provider

Known Allergies (medications, food, environmental)

Current Medications (name and dose)

Significant Medical History / Chronic Conditions

Hospitalizations or Surgeries (include dates)

Has the child had any fractures or serious injuries?

Yes No

If yes, describe

Immunization History

Is the child up to date on immunizations?

Yes No

Do you have a copy of the child's immunization record?

Yes No

Where were immunizations last given (provider / clinic name)?

Any reactions to previous vaccines?

Yes No

If yes, describe reaction

Preferred Pharmacy

Pharmacy Name

Phone

Address

Consent & Signature

I hereby authorize Monclova Road Pediatrics to provide medical care for my child. I authorize the release of any medical information necessary to process insurance claims and assign benefits to the provider.

I understand that I am financially responsible for all charges not covered by my insurance. I agree to the practice's financial and appointment policies as outlined during registration.

Signature of Parent / Guardian

Date

Printed Name

Relationship to Patient

Office Medical History Intake Form (PDF)

You may also review and print our office intake form below to bring to your first appointment.

Open / Print Form

Please return the completed form to the front desk. Thank you for choosing Monclova Road Pediatrics!

Medical History Form

Patient Information

Birth History

Developmental History

Previous Medical History

Family Medical History

Social History

Immunization History

Review of Systems

Preferred Pharmacy

Consent & Signature