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115 Norwood Park South Suite 110, Norwood, MA 02062

122 Grove Street 2nd Floor, Franklin MA 02038

781-769-4090 or 508-528-5404

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Family Medical History Form

Pediatric Associates

115 Norwood Park South, Suite 115, Norwood, MA 02062

(p): 781-769-4090, Fax: 781-769-6485

122 Grove Street, Franklin, MA 02038

(p): 508-528-5404, Fax: 508-528-5383

Which office location do you prefer?*

Norwood

Franklin

Parent 1 : *

First name*

Last name*

Parent 2 : *

First Name*

Last Name*

Mother's # of pregnancies*

# of living children*

Child 1: *

First Name*

Last Name*

Date of Birth:*

Child 2:

First Name

Last Name

Date of Birth:

Child 3:

First Name

Last Name

Date of Birth:

Child 4:

First Name

Last Name

Date of Birth:

Check yes or no to indicate if the following illness are present in your family. If YES, please give further explanation in the text box, providing WHO has the illness and WHAT their relation is to the patient(s).

Please ONLY include child(ren)'s biological parents, grandparents, aunts, uncles, cousins, and siblings (including half or step siblings).

Food Allergies*

Yes

No

If yes, relation to the patient(s)

Asthma*

Yes

No

If yes, relation to the patient(s)

Bleeding Disorder*

Yes

No

If yes, relation to the patient(s)

If yes, provide detail (if known)

Inflammatory bowel disease (Chron's disease or Ulcerative colitis disease)*

Yes

No

If yes, relation to the patient(s)

Celiac Disease*

Yes

No

If yes, relation to the patient(s)

Cancer*

Yes

No

If yes, type of cancer (if known)

If yes, relation to the patient(s)

Sudden Infant Death Syndrome (SIDS)*

Yes

No

If yes, relation to the patient(s)

Deafness (before age 40)*

Yes

No

If yes, relation to the patient(s)

Diabetes requiring insulin shots*

Yes

No

If yes, relation to the patient(s)

Drug or alcohol addiction*

Yes

No

If yes, relation to the patient(s)

Seizure disorder*

Yes

No

If yes, relation to the patient(s)

Kidney abnormalities*

Yes

No

If yes, relation to the patient(s)

Bladder reflux*

Yes

No

If yes, relation to the patient(s)

Bladder Heart attack before age 60*

Yes

No

If yes, relation to the patient(s)

High cholesterol (requiring medication)*

Yes

No

If yes, relation to the patient(s)

Mental illness*

Yes

No

If yes, relation to the patient(s)

Severe Developmental Delay*

Yes

No

If yes, relation to the patient(s)

Autism Spectrum Disorder*

Yes

No

If yes, relation to the patient(s)

Learning disabilitiesADHD*

Yes

No

If yes, relation to the patient(s)

Thyroid disease*

Yes

No

If yes, relation to the patient(s)

Migraine headaches*

Yes

No

If yes, relation to the patient(s)

Other medical history you think it is important for your doctor to know*

Yes

No

If yes, relation to the patient(s)*

Please click, "Submit to Pediatric Associates" to send electronically, or print this form and deliver it to our office.

I understand that the information submitted may include personal health information and consent to its secure storage and use.

© 2026 by Pediatric Associates of Norwood and Franklin

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