Health History Form - Paul Young MD

Today’s Date YYYY-MM-DD format

General Information

First Name

Last Name

Social Security Number:

Date of Birth: YYYY-MM-DD format

Address 1:

Address 2:

City

State

Zipcode

Phone Numbers

Home

Cell

Work

If we need to contact you, which is the preferred number?

Home Cell Work

Can we leave a message at this number on the answering machine?

Yes No

Are there other members of the household that we may leave the message with regarding your health matters?

Yes No

If so, whom?

E-mail Address

E-mail address (Required Field)

Work

Occupation

Employer

Preferred Pharmacy

Pharmacy Name

Pharmacy Address

Government regulations

Require we ask for the following identifying information.

Gender

Female Male

Race

Caucasian African American American Indian/Alaska Native Asian

Other Race

Ethnicity

Non-Hispanic Hispanic

Primary Preferred Language

English Spanish

Other Language

How did you hear about our practice?

Physician Referral

Doctor’s Name:

Friends / Family

Whom may we thank?

Web Search Social Media Other:

Primary care Doctor’s Name:

PEDIATRIC REVIEW OF SYSTEMS

Respiratory:

Cough Shortness of Breath (At Rest) Wheezing

Cardiovascular:

Chest Pain (At Rest) Irregular Heartbeat

Ophthalmologic (Eyes):

Blurred Vision Pink Eye/Conjunctivitis Vision Problems

Musculoskeletal:

Painful Joints Swollen Joints

Skin:

Itching Rashes

Neurologic:

Headaches Dizziness

Genitourinary:

Blood In Urine Painful Urination Bedwetting

PAST MEDICAL HISTORY

Cancer history:

Other Medical History:

SOCIAL HISTORY

Is the patient in Daycare?

Yes No

Is there smoke exposure at home?

Yes No

Are the patient’s immunizations up to date?

Yes No

Does the patient have brothers and/or sisters?

Yes No

If YES, how many?

Family HISTORY

(Please check symptoms below to indicate.)

Do any of these diseases run in your family:

Diabetes

Maternal Paternal

Heart Disease

Maternal Paternal

Anesthesia Complications

Maternal Paternal

Cancer

Maternal Paternal

Bleeding Disorders

Maternal Paternal

Others

PAST SURGICAL HISTORY

Please list previous surgeries:

CURRENT MEDICATIONS

Please indicate doses and how often you take.

Pediatric Patient Health History Form

General Information

Phone Numbers

E-mail Address

Work

Preferred Pharmacy

Government regulations

How did you hear about our practice?

PEDIATRIC REVIEW OF SYSTEMS

PAST MEDICAL HISTORY

SOCIAL HISTORY

Family HISTORY

PAST SURGICAL HISTORY

CURRENT MEDICATIONS

ALLERGIES TO MEDICATIONS