St Christopher's Hospital for Children
Section of Neurosurgery
Medical History Worksheet

Please complete this questionnaire to help your doctor gather a complete and detailed history of your child's condition. Do not be concerned if you cannot answer every question - the doctor will review the most important pieces of information with you.

Patient Name

Date of Birth

St Christopher's Hospital for Children Medical Record No. (if available)

How long was the pregnancy?
Were there any complications of the pregnancy? (premature labor, bleeding, infection, diabetes, injury, bed rest requirement, twinning?)

Was the delivery induced or spontaneous ?
Position of the baby at delivery: normal , breech , transverse , other
Were instruments (vacuum extractor , forceps ?) used by the obstetrician?
What was your child's birth weight?
Were there any complications of delivery?
When did your child come home from the hospital?

At what age did your child first ...

roll over?.............................
sit independently? ....................
play with feet?........................
crawl?.................................
pull to stand?.........................
cruise?................................
walk independently?....................
speak an intelligible word?............
put 2 words together?..................
When was your child toilet trained?...

Does your child have ALLERGIES to medications?

Current MEDICATIONS?

Has your child had any OPERATIONS? Has your child had any serious illnesses or been hospitalized for any reason?

Are your child's IMMUNIZATIONS up to date? (yes , no )

Who lives at home?
How many brothers and sisters altogether?

Ages?

What is father's occupation?

What is mother's occupation?
Has your child lived or traveled outside of this country? (yes , no ) Where?

If your child is in school, what grade?
Is your child a good student? What kind of grades does your child earn?

Is your child in any special classes? (yes , no ) Does your child have an Individual Educational Plan (IEP)? (yes , no )
Does your child receive any therapy services at school or in the community? (yes , no )

Are there any medical conditions passed from generation to generation in your family?

Are there any serious medical conditions in the immediate family?

Does any family member have …
severe headaches or migraine?
seizures?
a brain tumor?
a large head or any other skull deformity?
coffee-colored birth marks?
frequent nose bleeds, bleeding after dental work, or other unusual bleeding or bruising?

How is your child's temperment? Appetite? Sleep? Growth?

Does your child have any problem with vision? Spectacles? Squint? Double vision?

Does your child have any problem with hearing? Speech? Swallowing? Bloody noses? Ear infections?

Does your child have high blood pressure? A heart murmur? Can your child keep up with other children at play?

Does your child have frequent colds? Cough a lot? Wheeze?

Does your child have abdominal pain? Vomit unexpectedly? Have constipation, diarrhea, or blood in feces?

Does your child have bowel or bladder accidents? Bladder infections? Has your child ever had blood in the urine?

Does your child complain about pain in joints? Muscle aches?

Does your child have birth marks? Rashes? Cuts, sores, or ulcers that heal very slowly?

Does your child have headaches? Seizures? Faint? Complain about dizziness? Is your child more clumsy than other children?

Does your child have emotional difficulties? Sadness? Anger or rage? Compulsions? Disturbing thoughts? Unusual restlessness?

Does your child have as much energy as other children? Does your child drink an unusual quantity of liquids? Get up at night to drink water? Get up at night to urinate? Is your child much shorter or taller than you might have expected based on the growth of other family members? Did your child begin to develop pubic hair or other sexual characteristics earlier or later than you expected?

[As appropriate: Has your child begun to menstruate? At what age? Are her periods regular? When was her last period?]

Does your child get large bruises after minor injuries? When your child has had a cut, abrasion, or laceration, has the bleeding stopped after an ordinary period of time? Has your child had frequent nose bleeds or unusual bleeding after dental work?

Does your child have seasonal allergies or "hay fever"? Does your child have allergies to foods, pets, soaps or detergents, dust, insect bites? Does your child get hives or other sudden rashes?

Please sign and date:

____________________________________Date:________________

I have reviewed this form with the patient or the patient's parent(s):

____________________________________Date:________________

When you have reviewed your responses, please press the "Submit" button to e-mail this form to the office of the Section of Neurosurgery. Or press the "Reset" button to start all over. The doctor will review the information that you submit and ask you to sign this form at your child's appointment. Thank you very much for your cooperation.

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