Please fill in all known information

Birth History: Birth Hospital:

Weight: Length: Birth date:
Delivery Type (Circle all that apply):
Vaginal C-Section
Full Term Premature_____wks
Blood Type – Mother: Baby: Coombs:
Feedings (circle): Breast Formula
Hepatitis Shot (circle): Yes No
Complications:
Childhood History:
Medications:
Allergies to medications/foods/environment?
Surgeries:
Other Hospitalizations:
Childhood Diseases (circle):
Chicken Pox Asthma RSV Croup
Other:
Immunization (circle): Current Behind Not Sure
Medical Problems:
Family Medical History:
(Check if any family member has any of the following)
This Other
Child Parents Siblings Relative
Allergies/Hay Fever ___ ___ ___ ___
Asthma/Wheezing ___ ___ ___ ___
Eczema ___ ___ ___ ___
Frequent Headaches ___ ___ ___ ___
Frequent Ear Infections ___ ___ ___ ___
Eye Problems ___ ___ ___ ___
Heart Murmur ___ ___ ___ ___
Heart Disease ___ ___ ___ ___
High Cholesterol ___ ___ ___ ___
High Blood Pressure ___ ___ ___ ___
Urinary Tract Infections ___ ___ ___ ___
Diabetes ___ ___ ___ ___
TB/Positive Skin Test ___ ___ ___ ___
Hearing Problems ___ ___ ___ ___
Birth Defects ___ ___ ___ ___
Seizures/Convulsions ___ ___ ___ ___
Learning Problems ___ ___ ___ ___
Mental Illness ___ ___ ___ ___
Anemia ___ ___ ___ ___
Bedwetting ___ ___ ___ ___
Bleeding Disorder ___ ___ ___ ___
Cancer ___ ___ ___ ___
Medication Reactions ___ ___ ___ ___
Douglas R. Coombs MD, FAAP
520 East Medical Drive Suite 301
Bountiful, Utah 84010
(810) 292-1464
Name_________________________________________
ALLERGIES: _________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Date Problems Resolved
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
___________________________________________________