Parents/Guardian please complete this entire page

Date / Last Name / First Name / MI / Nickname
Date of Birth / Age / Male / Female (circle) / Home PhoneCell Phone
Address / City/State / Zip Code
Mother / Occupation / Work Phone
Father / Occupation / Work Phone
Legal Guardian / Occupation / Work Phone
Pediatrician/Primary Care Doctor / MD Phone
Other doctors involved with your child’s care:

HISTORY Please explain any YES answers in detailed description in the box provided

Has your child ever had any
surgery or been hospitalized? / yes
no
Has your child ever had either
general anesthesia or sedation? / yes
no
Is there a family history of
problems with anesthesia? / yes
no
Is your child currently taking
any medications or drugs? (over the counter, prescription, birth control) / yes
no / (Include dosages)
Does your child have any allergies? (hayfever, meds, food, reaction to blood tx) / yes
no

FAMILY HISTORY Please indicate if the child’s parents, grandparents or siblings have any significant medical illnesses:

______

______

MEDICAL HISTORY Has the child ever been diagnosed with any of the following? If yes, please check any that apply and explain in the space provided.

BIRTH HISTORY
Birth weight______
C-section Premature
Apnea Bradycardia
Retinopathy Respirator
BPD or chronic lung disease / Normal full-term
Other/details / EAR, NOSE & THROAT
URI Loose teeth Braces
Hearing loss Removable appliance
Blindness Braces
OM Snoring
Nosebleeds Swallowing Problems / Normal
Other/details
CARDIAC
High Bld Pressure Arrhythmia Cardiotoxic Drugs Murmur
Congenital Abnormality / Normal
Other/details / MUSCULOSKELETAL
Muscle Disease Scoliosis
Previous Fractures Back pain
Hypotonia Contractures / Normal
Other/details
RESPIRATORY
Asthma Croup TB
Pneumonia Bronchitis RSV
Aspiration Tracheostomy
Chronic Cough Wheezing / Normal
Other/details / BLOOD DISORDERS
Bleeding disorder Sickle cell
Prior transfusion Anemia Lymphoma Leukemia
Easy bleeding/bruising / Normal
Other/details
GENITOURINARY
UTI
Kidney disease / Normal
Other/details / SKIN
Rash Birthmarks Bruises
Eczema Scars Hemangioma / Normal
Other/details
HEPATIC
Liver Disease Jaundice Hepatitis / Normal
Other/details / ENDOCRINE/METABOLIC
Diabetes Thyroid Adrenal / Normal
Other/details
NEUROLOGIC
Cerebral Palsy Weakness
Migraines Seizures
Head bleed (infant)
Myopathy Hydrocephalus / Normal
Other/details / PSYCHOSOCIAL
Developmental delay Drug abuse
Learning disability Autism
ADHD ADD / Normal
Other/details
GASTROINTESTINAL
Vomiting Diarrhea
Constipation Reflux / Normal
Other/details / For patients > 10 complete following:
Tobacco use Yes ___ No ___
Alcohol use Yes ___ No___
Recreational Drug Yes ___ No ____ / Immunizations:
UTD Yes ____ No _____
If not UTD, list: ______
Why are you here to see the doctor?

Yes ___ No ___ Are there persons who cannot receive information about this child? List: ______

H&PForm3.doc1/18/08