PEDIATRIC GASTROENTEROLGY HEPATOLOGY & NUTRITION CLINIC
New Patient History Form
(Please fill out this form and bring it with you to your appointment)
CHILD’S NAME:______PRIMARY DOCTOR: ______
PHARMACY you want to use: Name:______
Street: ______City: ______
Why are you bringing your child to the GI clinic?______
When did the problem start? ______
How often does the problem occur?______
FAMILY HISTORY: (Circle ALL that apply)
Does ANYONE in the family have the following illnesses on mother or father’s side,
Including parents, siblings, first cousins, grandparents, aunts or uncles, etc.?
SEIZURES, MIGRAINES, HEART ATTACKS/DISEASE, STROKE, ASTHMA, ECZEMA, ALLERGIES, HIGHBLOOD PRESSURE, THYROID DISORDER, DIABETES, ULCERS, GALL STONES, ULCERATIVE COLITIS, CROHN’S DISEASE, MISCARRIAGES, GASTROINTESTINALSURGERY, POOR GROWTH, POOR WEIGHT GAIN, SUDDEN INFANT DEATH SYNDROME, APNEA, DIARRHEA, CELIAC DISEASE, LIVER PROBLEMS, KIDNEY PROBLEMS, BLEEDING PROBLEMS, LACTOSE INTOLERANCE, CONSTIPATION, HEARTBURN (REFLUX), COLON CANCER, ESOPHAGEAL CANCER, AND OTHER CANCERS (list types), OTHER ILLNESSES?
______
AGES & SEX OF BROTHERS AND SISTERS:
______
MOTHER’S PAST MEDICAL HISTORY WITH THIS CHILD:
Any problems during pregnancy with this child: (Bleeding, infection, premature labor, medications taken during pregnancy, other): ______
Any problems during delivery? (Premature, infection, Cesarean, resuscitation, other)
______
Any problems in the nursery? (Jaundice, infection, not passing stool, other)
______
Patients’ birth weight: ______
PATIENT’S PAST HOSPITALIZATIONS & SURGERIES:
Reason Date Name & Location of Hospital
______
______
______
PATIENT’S SIGNIFICANT ILLNESSES: (Circle & explain ALL that apply)
Heart problems, Lung problems, Bladder/kidney infection, Seizures, Cancer, Blood pressure problems, Bleeding problems, Asthma, Seasonal allergies, Mental illness, ADD, ADHD, Others
(list below)
If patient is female: Date patient’s periods first started? ______
Are they regular (circle)? Yes / No
DEVELOPMENTAL HISTORY OF CHILD: Normal ______Delayed ______
TRANSFUSION HISTORY: Has your child received any blood products? Yes/No
DIET HISTORY: Does your child eat the following?
Sugarless gum or sugarless candy (circle)? Yes/ No/ Unknown
Fruit juice, non-diet soda, sports drinks. Does child consume greater than 8oz a day
of those types of drinks frequently (circle)? Yes/ No/ Unknown
Dairy products (circle)? Yes/ No/ Unknown ;Ounces per day consumed______
Fruit or vegetables: 5 or more per day (circle)? Yes/ No/ Unknown
Fluid (not including milk): Greater than 1 quart per day (circle)? Yes/ No/ Unknown
Type of drinking water (circle)? : Well /Bottled /City
Ground fresh water exposure; i.e. exposure to lakes, rivers, streams, etc. (circle)? Yes / No
Is your child is on a special diet (circle)? Yes/No Low cholesterol, Gluten free,
Lactose free, Other______
DIET: Please indicate the formula your child is on, how many ounces your child takes at a time, and how many times per day the formula is taken. Also, indicate the amount of water or juice your child takes per day. Please indicate whether your child can be orally fed or takes their feedings by gastrostomy tube. (Example: 8oz Pediasure 4 times a day. 1oz water 4 times a day).
______
______
______
SOCIAL HISTORY:
Child’s grade in school: ______Performance (circle): good /average/poor
Who lives with child? ______
Does child have friends (circle)? Yes/ No/ Unknown
Stressful events at school (circle)? Yes/ No/ Unknown (explain)
Stressful events at home (circle)? Yes/ No/ Unknown (explain)
Smoking or chewing tobacco by child (circle)? Yes/ No/ Unknown
Drugs or alcohol use by child (circle)? Yes/ No/ Unknown
Tattoos or piercing of child (circle)? Yes/ No/ Unknown
Is child sexually active (Circle)? Yes/ No/ Unknown
Mother’s Occupation______Father’s Occupation______
Marital status of child’s parents (circle)? Married, Separated, Divorced, Single, Widowed
Child’s Animal/Pet exposure (Dogs, cats, birds, etc.)? ______
Travel outside the state (circle)? Yes /No Date: ______Location: ______
MEDICATIONS: Please list all the medications your child is on, the dosage, and the number of times per day your child takes the medication. (If there are a number of medications, you may copy the medication list and staple list to this page). Please remember to write down the milligrams of the tablet or capsule your child is on or milligram/milliliter or the liquid of the medication your child is on. (Don’t forget vitamins, herbal medications, inhaled medications, and medicated ointments)
______
______
PLEASE CHECK ANY OF THE FOLLOWING SYMPTOMS YOUR CHILD HAS OR HAS HAD RECENTLY
GENERAL
/YES
/NO
/HEAD
/YES
/NO
Tiredness
/ / /Frequent sore throat or hoarseness
/ /Fever
/ / /Frequent cavities
/ /Decreased activity
/ / /Visual or hearing problems
/ /Decreased appetite
/ / /Frequent ear or sinus infections
/ /Missing school
/ / /Mouth sores
/ /Poor weight gain/weight loss
/ / /Swallowing problems
/ /Excessive weight gain
/ / /Retching/gagging/choking
/ /Poor sleeping
/ / /Pain on swallowing
/ /Irritability/Increased crying
/ / /Food getting stuck after swallowing
/ /CHEST
/YES
/NO
/NERVOUS SYSTEM
/YES
/NO
Stopped breathing
/ / /Seizures
/ /Turned blue
/ / /Depression
/ /Shortness of breath
/ / /Change in personality
/ /Cough
/ / /Anxious
/ /Wheezing
/ / /Headache
/ /Pneumonia
/ / /Difficulty with school
/ /Bronchitis
/ / /Dizziness
/ /Chest pain
/ / / / /GASTROINTESTINAL
/ YES / NO / KIDNEYS/BLADDER/REPRODUCTION / YES / NOAbdominal bloating / Pain on urination
Abdominal pain / Frequent urination
Nausea / Blood in urine/Dark urine
Vomiting / Irregular or painful periods
Diarrhea / Discharge from penis or vagina
Constipation /
BONES/MUSCLES/JOINTS
Vomiting blood / Joint painBlood in the stool / Joint swelling
Black stool / Back pain
Pale stool /
SKIN
Excessive burping / RashExcessive gas / Bruises or bleeds easily
Regurgitation / Eczema
Please list other physicians following your child so that we can send them a letter and update them on your child’s progress. Please indicate whether your child is being followed by other agencies such as, CCS, CVRC, Home Health Nursing, etc.
______
IMMUNIZATIONS UP TO DATE: Yes/No
ALLERGIES TO MEDICATIONS: (Please list medications and reactions):
______
Signature: ______Relationship to child: ______Date: ______Revised 12/09
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