Garden City Pediatric’s - Interval Family History Update

    1. Name of Parents (Guardian)

    2. Age

    3. Occupation

    Brothers & Sisters

    1. Name

    2. Age

    3. Date of Birth

    1. Name

    2. Age

    3. Date of Birth

    Who Else is Living at Home?

    1. Name

    2. Age

    3. Relationship:

    1. Name

    2. Age

    3. Relationship:


    2. Are there any smokers who live in the home? (required)YesNo

    Please check if blood relatives of child/patient have had any of the following:

    1. AsthmaEczemaAllergiesFood allergiesFrequent earinfectionsLazy eyeAnemiaBleeding problemsThyroid diseaseHeadachesMigrainesSeizures

    2. Heart attack before age 50High blood pressureHigh cholesterolDiabetesSkin cancerLearning problemsADD/ADHDMental IllnessDepressionAnxietyAlcoholismSuicide

    1. Are there any questions or concerns for today’s visit?

    * Required