Jeffrey S. Masin, MD

3085 W. Market St., Suite 102Fairlawn, Ohio 44333

330-379-9070fax 330-379-2358

Pediatric Health History (complete both pages)

Child’s name (please print) __________________________________________Today’s date _____________Reason for seeing the Doctor ________________________________________________________________When did this problem begin _________________________________________________________________

PAST MEDICAL HISTORYDoes your child have any medical problems diagnosed by another doctor? Yes NoIf yes, list them:___________________________________________________________________________

ALLERGIESIs your child allergic to any medications, grasses, pollens, foods, etc.? Yes No If yes, please list:__________________________________________________________________________

MEDICATIONSIs your child taking any prescription or over-the-counter medications? Yes No If yes, list beginning with the most recent medication or SEE ATTACHED LISTType and Strength__________ Dosage___________Reason for taking_________Prescribing Dr. __________Type and Strength__________ Dosage___________Reason for taking_________Prescribing Dr. __________Type and Strength__________ Dosage___________Reason for taking_________Prescribing Dr. __________Type and Strength__________ Dosage___________Reason for taking_________Prescribing Dr. __________Has your child ever been hospitalized? Yes No If yes, list beginning with the most recent:____________________________________________________________________________________________________Has your child had any surgeries? Yes No If yes, list beginning with the most recent:________________ ________________________________________________________________________________________

BIRTH HISTORYWas your child premature? Yes No If yes, how many weeks?___________________________________ Was your child in the NICU after birth? Yes No If yes, for how long?______________________________

IMMUNIZATION HISTORYAre your child’s immunizations up-to-date? Yes No If no, then what shots have been missed?________________________________________________________________________________________

SOCIAL HISTORYWho lives at home with the child?_____________________________________________________________Do you have pets? Yes No How many and what type?________________________________________

FAMILY HISTORYHas anyone in your family had symptoms similar to those you are here for today?_______________________Had tonsils/adenoids removed? Yes No Had recurrent ear infections? Yes No Had tubes placed in the ears? Yes No Asthma Yes No Hearing Loss Yes No Bleeding problems Yes No Seizures Yes No Speech or Language Delay Yes No Allergies Yes NoExplain YES responses, especially who they are and the age they were first affected:____________________________________________________________________________________________________________Are your child’s parents, brothers and sisters alive and well? Yes No If No, explain:_________________________________________________________________________________________________________

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Jeffrey S. Masin, MD

Review of SystemsHas your child had any of the following symptoms recently? Explain next to the question.Constitutional symptomsPoor Feeding/Difficulty Feeding � Yes � No ___________________________________________________Poor Weight Gain � Yes � No ______________________________________________________________EyesFrequent Pink Eye � Yes � No _____________________________________________________________Ears, Nose, Mouth, ThroatFrequent Ear Infections � Yes � No _________________________________________________________Frequent Sore Throats � Yes � No _________________________________________________________Loud Snoring � Yes � No _________________________________________________________________Frequent Upper Respiratory Infections � Yes � No ______________________________________________CardiovascularHeart Murmur � Yes � No __________________________________________________________________RespiratoryShortness of Breath � Yes � No ____________________________________________________________Cough � Yes � No _______________________________________________________________________GastrointestinalReflux � Yes � No _______________________________________________________________________ Vomiting � Yes � No ______________________________________________________________________Genitourinary Bed wetting � Yes � No __________________________________________________________________Frequent urinary tract infections � Yes � No ___________________________________________________MusculoskeletalNeck/back pain � Yes � No ________________________________________________________________Arm/leg pain � Yes � No __________________________________________________________________IntegumentaryEczema � Yes � No _____________________________________________________________________Sensitive Skin � Yes � No __________________________________________________________________NeurologicalHeadaches � Yes � No __________________________________________________________________Developmental Delays � Yes � No __________________________________________________________Seizures � Yes � No _____________________________________________________________________PsychiatricBehavior problems/problems at school � Yes � No ______________________________________________Irritability � Yes � No _____________________________________________________________________EndocrineNot on the growth curve for height � Yes � No ________________________________________________Not on the growth curve for weight � Yes � No ________________________________________________Hematologic/LymphaticBleeding problems � Yes �No _____________________________________________________________Allergic/ImmunologicFrequent Allergy Symptoms � Yes � No ______________________________________________________

3085 W. Market St., Suite 102Fairlawn, Ohio 44333

330-379-9070fax 330-379-2358