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Patient Birth History Form (All Ages)

PLEASE NOTE:
This form must be filled out completely. If a question does not apply, please mark "No" and/or fill in the field with "N/A". All questions are important for our office to better serve our patients.

Email Address:


Phone Number:


Child's Name:


Form Filled Out By:


Date Filled Out:


Gestational age of child at birth was:
Preterm    Borderline Term    Term   
How many weeks?      

What was his/her birth weight?   

When did he/she pass Meconium within hours, days (date calendar):


When did he/she pass urine within hours, days (date calendar):


Antenatal problem present/ absent:   Present   

Was the prenatal course  Normal    Abnormal
If abnormal, please describe:


Was he/she placed on antibiotics?   Yes    No
If yes, why?


Was he/she on TPN (Date Calendar)?   Yes    No
If yes, how long?   

Was central line placed?   Yes    No
If yes, how long?   

Was he/she on a ventilator?   Yes    No
If yes, how long?   

Did he/she have Jaundice?   Yes    No
If yes, how long?   

What treatment was given for the Jaundice?   Phototherapy    Stop Breast Milk

What method of feeding was started after birth?
Breast Milk   Formula

If formula, select the brands used:
Similac    Enfamil    Soy    Elacare    Pregistamil    Nutragem    Neocate    Carnation   

How much does he/she eat?


Does he/she have formula intolerance?   Yes    No
If yes, please explain:


Is growth and development normal or abnormal, and please explain:


Is the child's weight gain normal or abnormal, and please explain:


Are there issues with spitting up, and please explain:


What is his/her stooling frequency during the day?


Are there problems with his/her stooling, and please explain:


Thank you for taking the time to fill out this form, we do appreciate your efforts. Your child's health is important to us, your answers will help us serve your child's needs better.