OKLAHOMA ORTHOPEDIC ONCOLOGY
PEDIATRIC HEALTH HISTORY QUESTIONNAIRE
NAME: ______TODAY’S DATE: ______
HEIGHT: ______WEIGHT: ______AGE: ______BIRTHDATE: ______SEX: M F
Student (where, what year?): ______
List current Medications: (please circle NONE if not currently taking any medications) ______
______
List any Medication Allergies: (please circle NONE if no known drug allergies) ______
______
Other Allergies: ______
Chief Complaint
For what reason are you seeing the Doctor today? ______
______
Date of first symptoms: ______Date you first consulted a Doctor for these symptoms: ______
Is the patient: Limping (if yes, how often, when?)______
Waking up at night complaining of pain (if yes, what relieves it?)______
Changed their level of activity (if so, how?) ______
Changed their eating habits (if so, how?) ______
Review of Symptoms
Do you now or have you ever had the following? (Please circle yes or no and explain any yes answers)
Heart trouble/chest painNo Yes ______
Stomach ulcers No Yes ______
DiabetesNo Yes ______
Blood diseases (anemia, other)No Yes ______
Abnormal Chest X-Ray (? TB) No Yes ______
Asthma/Emphysema/Bronchitis No Yes ______
CoughNo Yes ______
Epilepsy or Seizures No Yes ______
Hepatitis/Mono (indicate type)No Yes ______
Fever or Night sweats No Yes ______
Weight Changes (indicate gain or lossNo Yes ______
Bone pain (if yes, when?)No Yes ______
Cancer (what kind/when diagnosed?)No Yes ______
Positive HIV/AIDS testNo Yes ______
Arthritis (type)No Yes ______
MRSA infection (Where? When?)No Yes ______
Kidney disease/Bladder problemsNo Yes ______
Psychological problemsNo Yes ______
Are immunizations up to date? No Yes ______
Measles/Mumps/Chicken PoxNo Yes ______
Are you or could you be pregnant?No Yes ______
Are you Left or Right handed? L R ______
Patient Signature: ______Reviewed by: ______MD Date: ______
Parent or legal guardian signature: ______
HEALTH HISTORY QUESTIONNAIRE
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Past Medical / Surgical History
List previous surgeries and approximate dates: ______
______
______
______
Any abnormal reactions to anesthesia? ______
______
Any hospitalizations for non-surgical condition? (What condition/When?): ______
______
Do you have any chronic health conditions? (Such as Neurofibromatosis):
______
Family History
Any family history of significant medical illness, or cancer? (If yes, please describe problem and relationship to patient): ______
______
______
Pediatric Social History
In what type of dwelling do you live? ______
Are there any siblings? No Yes (if yes, how many?) ______Any health problems? ______
Are there stairs in your home? ______
Do you have any pets? No Yes (What/How many?)______
Do you exercise? ____ Daily ____Weekly ____Monthly ____Rarely ____Never
What do you like to do for exercise? ______
What do you do for fun? ______
Team Sports/Physical Education class?______
Patient Signature: ______Reviewed by: ______MD Date: ______
Parent or legal guardian signature: ______