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  • FAMILY HISTORY BIRTH - drselem · FAMILY HISTORY BIRTH: 1. Child was born at Hospital in City, in State. 2. Birth was [ ]Vaginal [ ]C-Section delivery. 3. Birth was [ ]Full Term [
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SAWSAN F. SELEM, M.D., F.A.A.P. 2700 Bellflower Blvd, Suite 201, Long Beach, CA 90815 T: (562)938-9711 F: (562)938-9701 www.drselem.com FAMILY HISTORY BIRTH: 1. Child was born at Hospital in City, in State. 2. Birth was [ ]Vaginal [ ]C-Section delivery. 3. Birth was [ ]Full Term [ ]Premature 4. Birth weight was lbs. oz. Length was inches. PREGNANCY: 1. During the PREGNANCY, were there any complications? [ ]YES [ ]NO 2. Did the mother have any of the following complications? [ ]High blood pressure. [ ]diabetes. [ ]drug use. [ ]use of medication. [ ]alcohol use. [ ]smoking. [ ]kidney problems. [ ]premature labor. [ ]hospitalization for illness. FAMILY HISTORY: None Child Family Details: Allergy to Meds or Food Anemia Blood Disorder Asthma Chronic Bronchitis Birth Defect Cancer High Cholestorol Mental or Developmental Disorder Diabetes Recurrent Diarrhea Drug Use/Abuse Frequent Ear Infections Eczema skin disease Hearing Loss Hepatitis, Jaundice High Blood Pressure Heart Attack, Early Age Stroke Speech Problems Surgery Epilepsy, Seizure Disorder Tuberculosis, +ve TB Skin Test Other

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Page 1: FAMILY HISTORY BIRTH - drselem · FAMILY HISTORY BIRTH: 1. Child was born at Hospital in City, in State. 2. Birth was [ ]Vaginal [ ]C-Section delivery. 3. Birth was [ ]Full Term [

SAWSAN F. SELEM, M.D., F.A.A.P. 2700 Bellflower Blvd, Suite 201, Long Beach, CA 90815 T: (562)938-9711 F: (562)938-9701 www.drselem.com

FAMILY HISTORY

BIRTH:

1. Child was born at Hospital in City, in State. 2. Birth was [ ]Vaginal [ ]C-Section delivery.3. Birth was [ ]Full Term [ ]Premature4. Birth weight was lbs. oz. Length was inches.

PREGNANCY:

1. During the PREGNANCY, were there any complications? [ ]YES [ ]NO2. Did the mother have any of the following complications? [ ]High blood pressure. [ ]diabetes.[ ]drug use. [ ]use of medication. [ ]alcohol use. [ ]smoking. [ ]kidney problems. [ ]premature labor. [ ]hospitalization for illness.

FAMILY HISTORY: None Child Family Details:

Allergy to Meds or Food Anemia Blood Disorder Asthma Chronic Bronchitis Birth Defect Cancer High Cholestorol Mental or Developmental Disorder

Diabetes Recurrent Diarrhea Drug Use/Abuse Frequent Ear Infections Eczema skin disease Hearing Loss Hepatitis, Jaundice High Blood Pressure Heart Attack, Early Age Stroke Speech Problems Surgery Epilepsy, Seizure Disorder Tuberculosis, +ve TB Skin Test Other

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