Today’s Date: YYYY-MM-DD format

GENERAL INFORMATION

First Name:

MI:

Last Name:

Social Security Number:

Date of Birth: YYYY-MM-DD format

Address 1:

Address 2:

City:

State:

Zipcode:

Parent / Guardian’s Name

First Name:

MI:

Last Name:

Address 1:

Address 2:

City:

State:

Zipcode:

Phone Numbers

Home:


Cell:


Work:

E-mail address (Required Field)

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

HomeCellWork

Does the above person have the legal authority to make medical decisions?

YesNo


If so whom?

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

YesNo

Preferred Pharmacy (Name & Address)

Pharmacy Name:

Pharmacy Address:

Government regulations require we ask for the following identifying information.

Gender: FemaleMale

Race: CaucasianAfrican AmericanAmerican Indian/Alaska NativeAsian

Other Race:

Ethnicity: Non-HispanicHispanic

Primary Preferred Language: EnglishSpanish

Other Language:

How did you hear about our practice?

Physician Referral
Doctor’s Name:


Friends / Family
Whom may we thank?

Web SearchSocial Media
Other:


Primary care Doctor’s Name:

Primary care Doctor’s Name:

PEDIATRIC REVIEW OF SYSTEMS

(If experiencing any of the below symptoms, please check.)

General Constitutional:

Change in AppetiteChillsFeverWeight LossExcessive Bruising / BleedingPassed New Born Hearing/Screening Test

Ear, Nose and Throat:

Frequent Ear InfectionsFrequent Sinus InfectionsFrequent StrepThroat/TonsillitisDecreased HearingRinging in EarsSpeech ProblemsLanguage DelaysMouth BreathingSnoring/Noisy BreathingHoarseness/VoiceFrequent Nosebleeds

Respiratory:

CoughShortness of Breath (At Rest)Wheezing

Cardiovascular:

Chest Pain (At Rest)Irregular Heartbeat

Ophthalmologic (Eyes):

Blurred VisionPink Eye/ConjunctivitisVision Problems

Gastrointestinal:

Abdominal PainDiarrheaVomitingGERD/Heartburn

Musculoskeletal:

Painful JointsSwollen Joints

Skin:

ItchingRashes

Neurologic:

HeadachesDizziness

Genitourinary:

Blood In UrinePainful UrinationBedwetting

PAST MEDICAL HISTORY

(Please check the symptoms below to indicate.)
Indicate if you have any of the medical problems listed below and add any additional problems not covered in the space provided.

Down’s SyndromeAutismLearning DisorderADHA / HyperactivityEnvironmental AllergiesPremature BirthRecurrent / Frequent CroupHeart DefectHeart MurmurHeart / Thoracic SurgeryAsthmaPneumonia OtherGERDKidney / Renal DiseaseDiabetesBleeding DisordersThyroid DiseaseHistory of Migraine HeadachesImmune DeficiencySeizuresEczemaHistory of CancerOther



Cancer history:

Other Medical History:

SOCIAL HISTORY:

Is the patient in Daycare?


YesNo


Is there smoke exposure at home?


YesNo


Are the patient’s immunizations up to date?


YesNo


Does the patient have brothers and/or sisters?


YesNo


If YES how many?

FAMILY HISTORY:

(Please check symptoms below to indicate.)


Do any of these diseases run in your family:

Diabetes MaternalPaternal side


Heart Disease MaternalPaternal side


Anesthesia Complications MaternalPaternal side


Cancer MaternalPaternal side


Bleeding Disorders MaternalPaternal side


Others

PAST SURGICAL HISTORY

Please list previous surgeries:

CURRENT MEDICATIONS

Please indicate doses and how often you take.

ALLERGIES TO MEDICATIONS