Child Initial History

CHILD INITIAL HISTORY FORM
If this is your child’s first visit to our practice, please fill out the following Initial History form before your visit. Note: If you would prefer to print a hard copy of the form and bring it with you on your visit, click here.
After you have filled out the form, hit the submit button at the bottom of the screen.
You will be redirected to a page indicating "Your Form Has Been Submitted to HFM."
PROVIDER INFORMATION
- Please select your HFM location:*
  - Clayton
  - Four Oaks
  - Riverwood
- Which Clayton Provider do you see?*
  - Dr. Williams
  - Dr. Harris
  - Dr. Kahn
  - Dr. McGill
  - Dr. Selak
  - Dr. Norris
  - Megan Wester, PA
  - Brittany McCall, FNP-C
  - Jenah Manzano, PA-C
  - Rebecca Johnson, FNP-BC
- Which Four Oaks Provider do you see?*
  - Dr. Watson
  - Hannah Brame, PA-C
- Which Riverwood Provider do you see?*
  - Dr. Hebda
  - Caroline Lewis, PA
PATIENT INFORMATION
Child's Name (First, Middle, Last):*
Date of Birth:*
1. What is the reason for today's visit?*
2. List all current medications:
Medication Name Strength How often? How long have you been on it?
3. Are there any medication allergies?*
- Yes (specify medications and reactions)
- No
Please list medications and reactions:
4. Who is the previous Care Provider?
Birth & Past Medical History
5. Birth weight:*
Length:*
Delivered:*
- Vaginally
- by C-Section
6. Birth timing:*
- Full-Term (37-40 weeks)
- Late (> 40 weeks)
- Premature (< 37 weeks)
7. Hospital and City of Birth:*
8. List any problems during pregnancy or delivery:
9. List any medicine used during pregnancy:
10. List any problems during newborn period:
11. List previous Hospitalizations and/or Operations:
Date of Hospitalization/Operation Reason
12. Check any past medical problems the child has had:*
- Asthma
- Allergies
- Frequent ear infections
- Seizures
- Skin problems
- Food/formula intolerance
- Learning problems
- Heart problems/murmur
- NO MEDICAL PROBLEMS
Feeding (only complete this section if child is less than 1 year old)
13. Liquids:
- Breast
- Bottle
Formula Type:
Amount of juice per day:
Amount of milk/formula per day:
14. Solid foods:
Fruit servings per day:
Vegetable servings per day:
Health Maintenance
15. Are your child’s immunizations current?*
- Yes
- No
Please upload an image of your child's immunization record, or provide a copy to the front desk.
Upload file here:
Drop files here or

Accepted file types: jpg, gif, png, Max. file size: 100 MB, Max. files: 1.
HABITS
16. Has your child had any unusual feeding or dietary problems?*
- Yes
- No
17. Has your child had any sleep problems?*
- Yes
- No
18. Do you live in a home built prior to 1972?*
- Yes
- No
19. Has your child been to the dentist?*
- Yes
- No
20. Do you use City Water?*
- Yes (specify city)
- No
If City Water, what City?
SCHOOL HISTORY
21. Does your child attend daycare / preschool / school?*
- Yes (specify name)
- No
Name of daycare / preschool / school:
22. Any concerns about school performance or relationships?*
- Yes (specify)
- No
School performance or relationship concerns:
FAMILY HISTORY
23. Please indicate if ANY family members have had the following:
Alcoholism:
- Father
- Mother
- Brother
- Sister
Asthma:
- Father
- Mother
- Brother
- Sister
Autoimmune Disorder:
- Father
- Mother
- Brother
- Sister
Bleeding Disorder:
- Father
- Mother
- Brother
- Sister
Cancer:
- Father
- Mother
- Brother
- Sister
Depression / Attention Problems:
- Father
- Mother
- Brother
- Sister
Diabetes:
- Father
- Mother
- Brother
- Sister
Genetic Problem:
- Father
- Mother
- Brother
- Sister
Heart Disease:
- Father
- Mother
- Brother
- Sister
High Blood Pressure:
- Father
- Mother
- Brother
- Sister
Kidney Disease:
- Father
- Mother
- Brother
- Sister
Stroke (CVS):
- Father
- Mother
- Brother
- Sister
Substance Abuse:
- Father
- Mother
- Brother
- Sister
Thyroid Problem:
- Father
- Mother
- Brother
- Sister
SOCIAL HISTORY
24. Who lives at home? (List names and relationship to patient)*
25. Are the child’s parents:*
- Married
- Unmarried
- Separated
- Divorced (specify when)
If divorced, when?
26. What are the parents' occupations?
Mother:
Father:
27. Who provides child care?
- Parents
Safety
28. Does the child ALWAYS:
Wear a bike helmet when riding?*
- Yes
- No
Wear a helmet, pads and wrist guards when rollerblading/skateboarding?*
- Yes
- No
Ride in a secure car seat or wear a seatbelt in vehicles?*
- Yes
- No
Wear sunscreen when outdoors?*
- Yes
- No
29. Is violence in the home a concern for you?*
- Yes
- No
30. Is there a gun in your home?*
- Yes
- No
If there is a gun in your home, is it locked apart from the ammunition?*
- Yes
- No
READ & SIGN BELOW
I certify that the information provided is correct and complete to the best of my knowledge.
Signature of Parent (or Legal Guardian):*
Date:*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.