Patient Name: MR#
Mother/Guardian’s Name: Ph #:
PMD: Ph #:
CC:
HPI:
This is the – hospitalization of this -- D/M/Y/O Hispanic/ African/Asian M/F.
Chronological description of the illness
Sick Contact:
History of Traveling:
Past History:
Hospitalizations:
Surgery:
Current Medications: (Since when)
Allergy to Medications or food: Type of reaction: describe the event
Pre natal History
Mother’s age: G: P: A:
Pregnancy problems: HTA, DM, other
Infection: GBS, Chlamydia, other
Admissions:
Drugs/Alcohol/Smoke:
Natal History:
Hospital: Lincoln, other
Weeks of gestations:
NSVD/CS/Vacuum FT/PT AGA/LGA/SGA
Birth Weight:
Apgar:
Complications:
Any problem at birth: jaundice, respiratory distress, etc
Neonatal Screening: result
Breastfeeding: for how long
Post Natal Hx:
Immunizations:
Card reviewed: Y N
Family History:
Asthma hx:
Asthma symptoms since:
Frequency of exacerbations:
# of Hospital admission due to asthma:
# of PICU admissions:
# of Intubations:
# of ER visits:
Date last Hospital admission:
Date last ER visit:
Triggers:
Asthma Risk Factors: (family hx of asthma, hx of eczema, allergies, eosinophilia, smoke exposure, hx of severe RSV infections)
Day time symptoms: (cough, wheezing, SOB frequency days/months)
Night Time symptoms: (cough, wheezing frequency days/months, exercise tolerance, sleep disturbances)
Menstrual Hx:
Menarche:
Regular cycle:
Frequency:
LMP:
Developmental:
Describe according to age
Home environment:
Apartment or house:
Where:
How many people live with pt: (who and age)
Smoking/Pets:
Education/Employment:
Last grade finished:
Grades:
School problems:
Work/employment:
Activities:
Drug use:
Suicidal Ideation:
Substance use:
Sexual Hx:
Currently sexually active:
Age of first sexual relation:
How many partners in the last year:
Male, female or both:
Use condoms:
Any other contraception:
Hx of STD:
Diet/Nutrition:
Formula: ounces and frequency
Foods:
Vegetarian:
Regular:
Annual Screening:
PPD: date and result
Lead:
CBC:
Review Of Systems:
General:
Growth and development:
___Healthy:
___Loss of appetite:
___Insomnia:
___Lipodistrophy:
___Fever:
___Fatigue:
___Night Sweat:
___Weight Loss:
___Weight gain:
Ophthalmology:
___Eye swelling:
___Red eye:
___Itchy eye:
___Eye pain:
___Visual disturbances:
___Blurry vision:
___Diplopia:
Cardiovascular
___Chest pain:
___HTN:
___Leg pain:
___Lower leg swelling:
___Murmur:
___Orthopnea:
___Palpitations:
___Post-nocturnal ___Dyspnea:
___Syncope:
ENT:
___Dec hearing:
___Tinnitus:
___Vertigo:
___Sinus/ear/tonsillitis/pharyngitis:
___Sneezing:
___Nasal discharge:
___Nasal obstruction:
___Nasal bleeding:
___Altered smell:
___Snoring:
___Mouth breathing:
___Sleep apnea:
___Hoarseness:
___Cough:
___Neck mass/pain:
___Thyroid mass:
___Enlarged glands:
Respiratory:
___Hx of pneumonia:
___Hx of asthma:
___Chest tightness:
___Cough:
___Exertional dyspnea:
___Dyspnea:
___Freq inhaler use:
___Hemoptysis:
___Murmur:
___Palpitations:
___Wheezing:
Gastrointestinal:
___Frequency of BM
___Abdominal pain
___Abnormal stools
___Nausea:
___Vomiting:
___Diarrhea:
___GI bleeding:
Genitourinary:
___Urine:
___Dysuria:
___Polyuria:
___Oliguria:
___Nocturia:
___Hematuria:
___Frequency:
___Urgency:
___Hesitancy:
___Dribbling:
___Poor stream:
___U retention:
___Incontinence:
___Hx of UTI:
___Enuresis:
___Edema:
___Flank pain:
___Sphincter control:
Musculoskeletal:
___Joint pain/stiff/swelling:
___Muscle pain/stiffness:
Integumentary:
___Bruises:
___Itching:
___Lesions:
___Pruritus:
___Rashes:
___Ulcers:
Neurologic:
___Headache;
___Apnea:
___Snoring:
___Diplopia:
___Sensory or motor deficits:
Psychiatry:
___Anxiety:
___Depression:
___Difficulty sleeping:
___Hyperactive:
___Nervousness:
Endocrine:
___Changes in hair/nails:
___Heat or cold intolerance:
___Polyuria:
___Polydypsia:
Hema/Lymphatic:
___Tender or draining nodes:
___Enlarged lymph nodes:
___Easy bruisability:
___Pallor:
Allergy/Immunology:
___Hives;
___Seasonal rhinitis:
___Sensitive to allergens: