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prediabetes clinic patient and family history form

Thank you for helping us better understand your concerns. We look forward to providing services to your family. This form is to be used by families after receiving contact from our office indicating that your referral has been accepted. If you have not received a referral to our prediabetes clinic, please talk to your child's primary care physician.

If you have any questions, please contact us at 937-641-3487.

background information

Does child have a primary care physician/other healthcare providers?

parental pregnancy history

At birth:

family background

Ethnic origin/Race:

sleep and elimination

medical history

weight history

How much did your child weigh at age (if you remember):
1 year2 years5 years
How much weight did your child gain:
last yearin last 2 years

level of concern about your child’s weight

Put mark from 0 to 5 (0 = no concern to 5 = very worried)

PersonLevel of concernName

symptoms and signs

Please check yes if your child has any of the following and then explain.

ConditionYes/NoHow many times a weekWhen did this startTreatmentSpecialist seenComments

metabolic syndrome family history

ConditionRelative of the child who has thisHow old was person when diagnosedTreatment (for diabetes write pills, diet or insulin)

family weight history

If you or any other of the child’s close relatives has had issues with obesity or weight gain, please comment below (including if they had any weight loss or weight surgery):

child development

At what age did your child:
Sit aloneWalk aloneFeed selfTalk (2-3-word sentences) Dress self
Toilet trained:
contact us schedule an appointment

The endocrinology department welcomes phone calls to 937- 641-3487 during our normal business hours of 8:00 am to 5:00 pm. After hours, you can dial 937-641-3000 and ask that the endocrinologist on call be paged.

Schedule you appointment online by visiting our scheduling page. All follow up appointments will be made during your clinic visit or by calling central scheduling at 937-641-4000.