11-12 Year-Old Forms

Interim History

Interim History Update


Current Contact Information

Mom's Relationship
Email verification
Email verification
Father's Relationship
Email verification
Email verification
Email verification

Interim Medical History

Current Prescription Oral Medications

Current Prescription Topical Medications (creams, etc.)

Current Prescription Inhaled Medications

Current Over-the-Counter Medications



Primary water source (for children under six)
Does this child (if under age three) live in or frequently visit a house constructed before 1978?



HIPAA Consent to Treat (Select Appropriate Clinic)

For which clinic is this form?
I (we), the legal quardians of the above named children do hereby give my(our) consent for the persons listed below to obtain medical care for my (our) children at Storybook Pediatrics. I (we) understand that by giving persons permission to take my child/children to Storybook Pediatrics for medical care, I am also giving Storybook Pediatrics permission to disclose my child's (children's) protected health information to any of the persons on this list. I also understand that by giving these persons permision to take my child (children) to Storybook Pediatrics for medical care that I am also giving these persons my permission to make medical care decisions for my child (children) during those visits. Parent or Legal Guardian Signature: *
Healthy Habits Child

Healthy Habits (Child)

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1. My child eats this many servings of veggies a day (a serving is about the size of your fist)
2. My child eats this many servings of fruits a day (a serving is about the size of your fist)
3. My child eats out
4. My child is active
5. My child has sweet drinks soda, sweet tea, 100% fruit juice, sports drinks, other fruit drinks)
6. My child watches television, plays video games, spends (non-school related) time on the computer, table, or cell phone
7. Most nights, my child sleeps
8. If you could work on one healthy habit, which would it be?






1. Is this child adopted? *
2. Are the medical records available or medical history known for parents or grandparents? *
3. Has either parent or any grandparents experience any of the following? Check all that apply.
4. Is this child overweight? *
5. If your child has risk factors for high cholesterol or early heart disease, are you interested in screening labs? *

Special Note

FAQ Sheet: Lipid Panels

The AAP recommends lipid screening beginning at age 8 years for the following populations:

*Obese children: defined as a BMI greater than the 95% for age (E66.9)

*Children whose parents or grandparents have had a heart attack, stroke, or blocked arteries younger than 65 in women and 55 in men (Z82.41, Z82.49)

*Children who have a parent or grandparent with a total cholesterol of 240 mg/dl or higher (Z83.42)

*Children whose family history is unknown. (Z84.89)

(Source: healthychildren.org 8/20/2020)

We at Storybook Pediatrics also recommend this screening.

We do recommend that you check with your insurance company prior to this lab draw to ensure that they will cover these labs.
The codes for the diagnoses are listed above. You can provide your insurance company with the appropriate codes

If your child is obese, we recommend the following labs:

Lipid panel

Hemoglobin A1C


If there is relevant family history or family history is unknown, we recommend the following:

Lipid panel

Alternatively, if you wish to do so, we can send the labs as self pay. The self pay prices are listed below for Lab Corp. Our phlebotomist can draw these labs and send them to the lab.

Lipid Panel: $102.90

Hemoglobin A1C: $69.30

ALT/AST: $77.70

Preparticipation Physical History 2023

Sports Pre-participation History

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Over the last 2 weeks have you experienced any of the following (check all that apply!)

Feeling nervous, anxious, or on edge
Not begin able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless

GENERAL QUESTIONS. Explain "Yes" answers.

1. Do you have any concerns that you would like to discuss with your provider?
2. Has a provider ever denied or restricted your participation in sports for any reason?
3. Do you have any ongoing medical issues or recent illness?


4. Have you ever passed out or nearly passed out during or after exercise?
5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise?
7. Has a doctor ever told you that you have any heart problems?
8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography.
9. Do you get light-headed or feel shorter of breath than your friends during exercise?
10. Have you ever had a seizure?


11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)?
12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndreme (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventrciular tachycardia (CPVT)?
13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35?


14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game?
15. Do you have a bone, muscle, ligament, or joint injury that bothers you?


16. Do you cough, wheeze, or have diffculty breathing during or after exercise?
17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ?
18. Do you have a groin or testicle pain or a painful bulge or hernia in the groin area?
19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)?
20. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems?
21. Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling?
22. Have you ever become ill while exercising in the heat?
23. Do you or does someone in your family have sickle cell trait or disease?
24. Have you ever had or do you have any problems with your eyes or vision?
25. Do you worry about your weight?
26. Are you trying to or has anyone recommended that you gain or lose weight?
27. Are you on a special diet or do you avoid certain types of foods or food groups?
28. Have you ever had an eating disorder?

Explain all Yes answers