PEDIATRIC UROLOGY ASSOCIATES, P.C.
PAST MEDICAL HISTORY FORM
Patient Name:_________________________________ Date of Appt:___________
Date of Birth:__________________
**Please fill in all circles completely. Do not mark with a check mark or “X”***
Social History
Alcohol/Drugs O Yes O No
Sexually Active O Yes O No
Day Care O Yes O No
Birth history O Full term O Premature
Breast feeding O Yes O No
Use of formula O Yes O No
On solid foods O Yes O No
Developmental milestones O Normal O Delayed
Family History
Mother O no problems O kidney problems O urinary reflux O UTI's
O kidney stones O voiding problems O bleeding problems O anesthesia
O heart arrhythmias O lidocaine allergy O alcohol abuse O drug abuse
O depression O anxiety O panic disorder O OCD
O ADD/ADHD O bipolar disease O phobias O dyslexia
Father O no problems O kidney problems O urinary reflux O UTI's
O kidney stones O voiding problems O bleeding problems O anesthesia
O heart arrhythmias O lidocaine allergy O alcohol abuse O drug abuse
O depression O anxiety O panic disorder O OCD
O ADD/ADHD O bipolar disease O phobias O dyslexia
Siblings O no problems O kidney problems O urinary reflux O UTI's
O kidney stones O voiding problems O bleeding problems O anesthesia
O heart arrhythmia O lidocaine allergy O alcohol abuse O drug abuse
O depression O anxiety O panic disorder O OCD
O ADD/ADHD O bipolar disease O phobias O dyslexia