New Patient Form Pediatric Cardiology

NEW PATIENT FORM – PEDIATRIC CARDIOLOGY

____Dr. Carroll ___Dr. Dayton ___Dr. Flynn __ Dr. Mirani __Dr. Steinberg

Patient Name: ______

Person Filling out Form: ______Relationship to patient: ______

Reason you were referred for visit: ______

Primary Care Physician: ______

Birth History:

Birth Place: ______

Birth Weight: ______Gestation: Full Term: ______

Premature: ______# Weeks: ______

Delivery: Vaginal______C Section: ______

Hospital: ______

Problems before / after birth: ______

Medical History: Has the patient had any of these heart problems? Explain Briefly.

Murmur: ______Asthma: ______

Palpitations:______Diabetes: ______

Fainting: ______Thyroid Problems: ______

Chest Pain:______Other Endocrine / Gland Disease______

Scoliosis: ______Poor Growth / Failure to Thrive: ______

ADHD: ______Neurologic Disease: ______

Cyanosis (Blueness): ______High Blood Pressure: ______

Arrhythmia: ______Lung Disease: ______

Seizures:______Joint / Rheumatologic Disease: ______

Marfan syndrome: ______Kidney Disease: ______

Cardiolmyopathy: ______

Prior Hospitalization:

Age _____ Diagnosis ______

Prior Surgery:

Age _____ Type ______

Social History: (Skip if Patient is < 10 Years Old)

Does the Patient Drink alcohol?______Use Street Drugs?______

Smoke Cigarettes?______Chew Tobacco?______

Does anyone smoke in the home? ______

**Please complete the second side of this questionnaire

Social Documentation:

Who lives at home with the patient? ______

If the patient attends school: School Name: ______Grade /year:______

Caffeine use by patient: Never: ______Occasionally: ______Daily:______

Physical Activity in which the patient participates:

Informal Recreation: ______

P.E. Classes: ______

Sports (please list):______

Dance: ______

Other Activity: ______

Family History: Note relationship to patients for example mother, uncle, grandmother

Congenital Heart Disease: ______

Heart Attacks: ______

Stroke: ______

Arrhythmia: ______

Sudden Cardiac Death: ______

High Blood Pressure: ______

Cardiomyopathy: ______

Marfan syndrome: ______

Diabetes: ______

Lipid Disorder: ______