DELAWARE MODERN PEDIATRICS, P.A.

David M. Epstein, M.D.

300 Biddle Avenue, Suite 206

Springside Plaza, Connor Building

Newark, Delaware 19702

Phone: (302) 392-2077

Fax: (302) 392 - 0020

www.DelawareModernPediatrics.com

Family History Child’s name:____________________ Date of Birth: _______

Today’s Date: _______

We are interested in the medical histories of:

• your child’s brothers and sisters
• you and your spouse (or child’s biologic parent)
• your brothers, sisters and parents

(The family histories of your cousins and grandparents is less relevant.)

Neurologic

Seizures

Mental retardation

Learning disability/dyslexia

ADHD

Hearing problems

Endocrine

Thyroid disease

Diabetes - child onset

Diabetes - adult onset

Obesity

Allergic

Asthma

Hay fever/Allergies

Food Allergies

Cardiovascular

Heart disease before age 60

High cholesterol

High blood pressure

Psychiatric

Depression

Suicide

Drug/Alcohol abuse

Panic attacks

Eating disorder

Other: