Paul R. Young, M.D. PLLC | Pediatric Patient Health History Form

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?



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




If so whom?


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



Preferred Pharmacy (Name & Address)

Pharmacy Name:

Pharmacy Address:

Government regulations require we ask for the following identifying information.

Gender:

Race:

Other Race:

Ethnicity:

Primary Preferred Language:

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:





Ear, Nose and Throat:





Respiratory:





Cardiovascular:




Ophthalmologic (Eyes):




Gastrointestinal:




Musculoskeletal:




Skin:




Neurologic:




Genitourinary:





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.





Cancer history:


Other Medical History:


SOCIAL HISTORY:

Is the patient in Daycare?





Is there smoke exposure at home?





Are the patient’s immunizations up to date?





Does the patient have brothers and/or sisters?





If YES how many?

FAMILY HISTORY:

(Please check symptoms below to indicate.)


Do any of these diseases run in your family:

Diabetes


Heart Disease


Anesthesia Complications


Cancer


Bleeding Disorders


Others

PAST SURGICAL HISTORY

Please list previous surgeries:



CURRENT MEDICATIONS

Please indicate doses and how often you take.



ALLERGIES TO MEDICATIONS