Child s Name: Date of Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT
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1 Date f Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT Prtable Medical Summary Name: Date Updated: / / Address: Phne: Mbile: DOB: SSN: - - Allergies: Pertinent Persnal Characteristics: What are yu like when yu feel gd? What are yu like when yu dn t feel gd? What d yu like when yu g t the dctr? What d yu nt like when yu g t the dctr? Primary Diagnsis Age: MEDICAL Medicatins Medical Prviders Rx Daily Rx Mnthly Primary Care Prvider Name Rx PRN (take as needed): Herbs/supplements: Immunizatins Please attach recrd
2 TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT Child s Name: Date f Birth: Medical Equipment Medical Supplies Prvider Cntact Inf Nutritin/Fitness Gals Prvider Cntact Inf Past Hspitalizatins (including surgeries) Date Hspital Name Reasn Physician Functinal Capabilities Brief Summary Future Plans (including agencies invlved &referrals made) Services Currently Receiving Prvider Cntact Inf HEALTH INSURANCE Primary: Cntact: Secndary Cntact: Health Surrgate Name: Hme # Wrk # Cell # Signature Yuth/Guardian: Date: Primary Care Prvider: (My dctr I see the mst) Address: Phne:
3 Date f Birth: FAMILY HEALTH HISTORY Bilgical Mther Pregnancy [ ] Nrmal [ ] Prblems: Type f Delivery: Immediate Cmplicatins: List any cnditins r illnesses f child s clse bld relatives (e.g. parents, brthers, sisters, uncles, aunts, grandparents): Cnditin/Illness: Family Member(s): Cmments: Alchlism/drug abuse r addictin Allergies Asthma Birth Defects Cancer Deafness Develpmental Disabilities Diabetes Heart Disease HIV Kidney Disease Seizures / Epilepsy Sickle Cell Other Genetic Cnditins
4 Date f Birth: DOCTOR S VISIT Name: DOB: Date: Existing Cnditins/Diagnses: Visit s Purpse: * + Physical Sick Visit * + Sprts/camp * + Immunizatin * + Other * PARENTS SECTION * PROBLEM S TO T AL K ABO U T TO D AY: MEDIC ATIO NS AND DO SA GES: * HEALTH CARE PROVIDERS SECTION * PROBLEM RE VIEW: * PHYSICAL EXAM * Cnditin Gen. E.N.T. Neck Lungs Heart Abdm. Mus./Skel/ Neur Skin Abnrmality explanatin: Height: Weight: BP: HR: Temp: Medical Changes: Testing Dates: Lcatin: Next CP: Vaccines due: Flu Sht: [ ] Yes [ ] N Due?: Dctr s Signature:
5 Date f Birth: ACTIVE PROBLEM LIST Active Prblem / Medical Diagnsis Diagnsis Date Current Treatment / Gals
6 Date f Birth: QUESTION / CONCERNS / OUTCOME Date Cncern Outcme
7 Date f Birth: PHYSICIAN S VISIT INFORMATION Child s Name: Date: Part A: T be cmpleted by the nurse caring fr the child (i.e. hmecare, medical daycare), r the parent/caregiver when the child presents with signs/symptms illness. If this is a rutine physician visit, please skip t Part B: Brief descriptin f assessment findings/symptms: Part B: Ntes t physician regarding the child s current status:
8 Date f Birth: RELEASE OF INFORMATION FORM Name f Child: Date f Birth: / / Address: City: State: Zip: I, hereby authrize print name f Parent/Guardian* (persn) f (name f dctr s ffice, schl, ther) t btain the fllwing infrmatin abut the abve-named child: (Check all that apply) [ ] all medical recrds currently n file at. [ ] nly the fllwing medical recrds currently n file at.
9 [ ] In additin, I authrize Child s Name: Date f Birth: (1) t release infrmatin cncerning the abve named child t: (2) t release infrmatin cncerning the abve named child t: This authrizatin will autmatically terminate n unless previusly revked r extended by me, the undersigned. Signature f Parent/Guardian* date I hereby revke this authrizatin Signature f Parent/Guardian* date I hereby extend this authrizatin fr mnths Signature f Parent/Guardian* date *If the patient is ver years f age, he r she may sign in place f parent/guardian. Adapted frm the aap
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