Health History
Content
HEALTH QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential and will become part of your medical record. Name
(Last, First, M.I.):
Baby K Dr. Jon Jantz
Previous or referring doctor:
DOB: 06/22/10 Date of last physical exam: 08/23/10 X M F
PERSONAL HEALTH HISTORY
Childhood illness: Immunizations and dates: Measles Mumps Rubella Chickenpox Rheumatic Fever IPV X @ 2 Months @ 4 Months @ 6 Months PVC X @ 2 Months @ 4 Months @ 6 Months Rota X @ 2 Months @ 4 Months @ 6 Months Polio X Non-Applicable
Hepatitis B X @ Birth X @ 2 Months DTaP X @ 2 Months @ 4 Months @ 6 Months Hib X @ 2 Months @ 4 Months @ 6 Months
List any medical problems that other doctors have diagnosed Born with immature lungs and experienced breathing problems within seconds of being born. He was hospitalized in the special care nursery for 4 days before lungs were mature and functioning normal.
All questions contained in this questionnaire are strictly confidential and will become part of your medical record. Name
(Last, First, M.I.):
Baby K Dr. Jon Jantz
Previous or referring doctor:
DOB: 06/22/10 Date of last physical exam: 08/23/10 X M F
PERSONAL HEALTH HISTORY
Childhood illness: Immunizations and dates: Measles Mumps Rubella Chickenpox Rheumatic Fever IPV X @ 2 Months @ 4 Months @ 6 Months PVC X @ 2 Months @ 4 Months @ 6 Months Rota X @ 2 Months @ 4 Months @ 6 Months Polio X Non-Applicable
Hepatitis B X @ Birth X @ 2 Months DTaP X @ 2 Months @ 4 Months @ 6 Months Hib X @ 2 Months @ 4 Months @ 6 Months
List any medical problems that other doctors have diagnosed Born with immature lungs and experienced breathing problems within seconds of being born. He was hospitalized in the special care nursery for 4 days before lungs were mature and functioning normal.
