newborn history form

1. NEWBORN HISTORY FORM
Name __________________________________________________ Age ____________
Date form completed _________________ Is your child adopted? __________
Race/ Ethnicity ____________________ Religion ___________________
A. BIRTH HISTORY
Date of Birth _________________________________________
Birth Place __________________________________________
Was the baby full term? ______________________ If early, how early? ____________
Birth Weight ________________________
Were there any problems with the delivery? ___________________________________
Any problems while in the nursery (jaundice, feeding problems, infections)?
________________________________________________________________________
B. MATERNAL PREGNANCY HISTORY
Were there any problems during the pregnancy (diabetes, high blood pressure,
infections)? _____________________________________________________________
Has birth mother ever had gonorrhea or Chlamydia infection ? _____________________
Did birth mother use alcohol, tobacco, or other drugs during this pregnancy?
___________________
How many times has birth mother been pregnant? _______________________________
Any premature births? ____________
Any stillbirths or spontaneous abortions? _____________
How many living children does birth mother have? ___________
C. FEEDING HISTORY
Breast feeding or Bottle feeding? __________________
If bottle feeding, what type of formula ?_____________________________
D. PREMATURITY/ NICU BIRTH HISTORY
Did your baby require admission to a neonatal intensive care unit? If so, where?
_______________________________________
Length of stay in the ICU: _______________________
Remainder of history will be obtained by your pediatrician during your appointment.
E. MEDICATIONS
Please list any vitamins or medications your baby is taking.
_________________________________________________________
F. ALLERGIES
Please list any allergies to foods or medicines.
________________________________________________________________________
________________________________________________________________________

2. G. FAMILY
Please list all family members (parents and all siblings). Include anyone who lives in the
same household with the patient.
Name (first and last) Age Relationship to Patient Health Problems Lives with
patient(y/n)
Mother
Father
H. FAMILY HISTORY
Has anyone had the following health problems? (Include siblings, parents, aunts and
uncles, cousins, and the child’s grandparents).
Asthma
Yes No
Allergies
Yes No
Eczema
Yes No
Diabetes
Yes No
Cancer
Yes No
Bleeding Problems
Yes No
Anemia
Yes No
High Blood Pressure
Yes No
Heart Attack
Yes No
Seizures (convulsions)
Yes No
Birth Defects
Yes No
Death in Infancy
Yes No
Alcohol/Drug Problems
Yes No
Mental Retardation
Yes No
Mental or Emotional Problems
Yes No
Suicide or Suicide
Yes No
_________________________________________ ___________________________
Reviewed by Physician Date