Health History 11-18 — Richfield Family Medicine

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Name *

Name

First Name

Last Name

What grade is the child in? *

If attending College what year?

Are there problems in school? *

If yes, what are the problems

Is the child often sad or depressed? *

Do you have a penis discharge?

Do you have a sore on your penis?

Are you sexually active? *

Do you use condoms?

Age of first period?

Painful Periods?

Do you use birth control

If yes, what do you use?

Smoke Detector in home? *

Does the child where seat belt in car? *

Does the child where a helmet when riding bike? *

Has the child had a dental check up? *

Has the child had a vision exam? *

Does the child have exposure to second hand smoke? *

Is the child exposed to lead? *

Is there any family abuse in your home? *

Is there any firearms in your home? *

Are they locked up?

Please list any allergies.

Please list Current Medications Name, dose, and how often taken

Please list all Hospitalizations reason and time frame.