First Name:
Last Name:
Date of Birth:
Weight:
Visit date:
Referral/Pediatrician:
What is your
Main Reason
for your child's visit today?
How long has this problem existed:
ALLERGIES/SENSITIVITIES TO MEDICATIONS:
None
CURRENT MEDICATIONS WITH DOSAGE:
None
Preferred Pharmacy Name & Cross Streets:
Preferred Pharmacy Phone #:
Immunizations:
Up to date
Delayed
Unvaccinated
Past Medical History
None
Asthma
Yes
No
Hay fever/Environmental allergies
Yes
No
Eczema
Yes
No
Food allergy
Yes
No
Hives
Yes
No
Anemia
Yes
No
Anxiety / depression
Yes
No
Arthritis
Yes
No
Bleeding disorder
Yes
No
Cancer
Yes
No
Diabetes mellitus
Yes
No
Ear infections
Yes
No
GERD (Reflux)
Yes
No
Hearing aid
Yes
No
Hearing loss
Yes
No
Heart disease
Yes
No
Hypertension
Yes
No
HIV/AIDS
Yes
No
Kidney disease
Yes
No
Hepatitis
Yes
No
Liver disease
Yes
No
Lung disease
Yes
No
Pneumonia
Yes
No
Chronic bronchitis
Yes
No
Seizures
Yes
No
Sinus disorder
Yes
No
Sleep apnea
Yes
No
Thyroid disease
Yes
No
OTHER MEDICAL PROBLEMS:
PAST SURGICAL HISTORY
PAST SURGICAL HISTORY:
BIRTH HISTORY
Birth Weight:
How many weeks gestation?
Pregnancy complications (list any)
NICU stay?
Yes
No
Newborn screen results
Normal
Unknown
Other
SOCIAL HISTORY
Who has legal custody of the child?
Parent 1
Parent 2
Other
Child lives with:
Parent 1
Parent 2
Other family
Foster family
Parents are:
Married
Not married
Partnered
Separated
Divorced
Child attends
Daycare
Preschool
School
Grade:
Number of siblings?
FAMILY HISTORY
None
Environmental allergies
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Eczema
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Asthma
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Medication allergy
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Cancer
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Diabetes
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Angioedema
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Immunodeficiency
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Autoimmune disorder
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Heart disease
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
High blood pressure
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Kidney disease
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Psychiatric illness
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Stroke
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Sudden death
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Thyroid disease
Parent 1
Parent 2
Sibling 1
Sibling 2
Child
Does anyone in your child's household smoke?
Yes
No
Visible mold or mold odors in the home?
Yes
No
Is there wall to wall carpeting?
Yes
No
Do you use humidifiers?
Yes
No
Any rodent or cockroach infestation?
Yes
No
ENVIRONMENTAL SURVEY
Pets?
Cat
Dog
Other
None
REVIEW OF SYMPTOMS
None
Decreased appetite
Fatigue
Fever/chills
Night sweats
Unintended weight loss
Vision changes
Eye pain
Chest pain
Difficulty breathing
Cough
Nausea/vomiting
Change in bowel habits
Skin rash
Mental status changes
Weakness
Numbness
Dizziness
Headache/migraine
Bleed easily
Bruise easily
Joint pain/swelling
Heat intolerance
Cold intolerance
Frequent urination
FORM COMPLETED BY:
The above information is accurate to the best of my knowledge.
Form completed by:
Relationship to patient:
Date:
Signature: