MarshallPediatrics Medical Center Drive, Suite 3500 (304)
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1 MarshallPediatrics 1600 Medical Center Drive, Suite !II:. ":n:' CabellHuntin~on Hospital MarshallHealth Huntington, WV PROVIDER BASEOFKIUTY OF CABEU HUNTINGTON HOSPITAL INC. (304) Pediatric Gastroenterology and Nutrition Questionaire, The purpose of this questionnaire is to provide University Pediatrics with Information about your medical concerns. Please answer the questions by circling "yes" or "no" or by completing the requested Information. Please answer all questions that apply to your child's medical history. Patient's Name Date of Blrth Date _ A - General Health 1. What Isthe reason for your visit? What Is the chief problem? 2. Are you concerned about any of the following? Please circle all that apply. Abdominal Pain Constipation Poor Appetite Soiling Reflux Weight loss Blood In Stools Poor Weight Gain Uver Problems Diarrhea Vomiting or Nausea Food Intolerance Nutrition Issues 3. How would you describe your child's current state of health? Excellent Good Fair Poor 4. Please describe any previous hospltallzatjons: 5. Please describe any previous surgeries: 1
2 6. Please describe any allergies; including medications: 7. Has there been any absence from school for more than 2 weeksi' 8. Please describe any other health problems: NO YES j/ 9. Name, address, and phone number of regular physldan/pedlatrlcian consulted for this problem: 10. list all medications and dosage your child Is currently taking - including over-the-counter and herbal therapies: 11. Are Immunizations up to date? B - Family History 1. Has anyone In your child's family had any of the following (Include child's grandparents)? If yes, pla.ce a check mark next to the appropriate Item and indicate the person's relationship to the child: Headaches Seizures Mental retardation/developmental delay ~ma,emphysema Cystic fibrosis Sickle cell disease or trait cancer (list type) High blood pressure Heart disease Diabetes Anemia High Cholesterol Constipation or Diarrhea Irritable Bowel Syndrome Gallstones Gastritfs/Ulcer Colitis, Crohn's disease Ceffae disease Uver probl:ems Rectal bleeding polyps Reflux Disease 2. Arethere any other diseases/illnesses that run In the family?
3 3. List all people living in the same household as your child: Name Age Relationship Any Health Problems # 4. Any drinking of untreated water? Please drde: lake Well Spring Stream 5. Has there been any foreign travel? 6. Are vitamins taken daily? 7. It you child exposed to dgarette smoke In the home '/ 8. It you child on any special diet? tryes, please describe. Social History: Housing: House Apartment Trailer Other Water supply: City Water Well water Other In house pets: Dog Cat Bird Other In house smoking: C - Review of Systems Please drcle any symptom or condition listed below pertaining to your chud. Describe details for each In the space below. 3GENERAL HEALTH GASTROtNT STINAL HEART Weight loss or poor gain Vomltlng_ Heart Defect Excessive weight gain Diarrhea Heart Murmur Feeding Problems Abdominal pain TIred during exercise Recurrent fevers Constipation PassIng'out/lIghtheaded Swollen lymph glands Food Intolerance or allergies LUNGS SKIN EYES Shortne$$ of breath Birthmarks Vision problems Wheettng Rashes Lazy eve (strabismus) Cough 'HEAD Eye.draining Genltourl!'lary Excessively large head EARS Urinary Intectlon excessively small head Hearing problems Kidney Olsease eulging soft spot far Infections Blood In Urine BACK UMBS/JOINTS Oefayed Toilet tralol1'!8 Spine defects Umb deformities loss of bladder or bowel control L..8ad<or neck pain Contractures Swollen or Painful joints 3
4 0 - Bowel Movements.. 1. Does your child have regular bowel movements'? If yes, move to E. 2. Number of Bowel movements per week: _ 3. Has there been any constipation? 4. Has there been any diarrhea? S. Cold and consistency of stool (please circle): Black or Tarry White like chalk Uke marbles loose (like scrambled eggs) Contains undigested food agar shaped Hard Watery So loose it runs down leg Contains mucous 6. Are stools larger than normal? 7. Are stools smaller than normal? 8. Is there excess straining with bowel movements? 9. Are bowel movements painful? 10. If there are several bowl movements per day, do most occur (please circle): Morning Evenings After eating During sleep During waking hours only 11. Isthere soiling. 12 Has there ever been blood In stool? If no, please g.oto section E. 13. Where was the blood seen? Please clrde: In the toilet water On the anus Coated on the stool On the toilet paper Mixed In the stool Streaked or spotted on the stool Only at the end of 8M Only at the end of 8M 14. Was the blood (please circle): 15. Was the bowel movement painful? Bright Red Dark Red Other Color SectJon E VomIting L. Has there been vomltlng or spitting up? (If no, move to section F) 2. Do stomach contents go up Into the throat and then get re-swallowed? 3. How many times a day? 4. Does If occur (please clrde): Before Meals During Meals After Meals S. Is there pain, crying and/or Irritability around the time of vomiting? 6. Is the vomiting (please circle): Saliva Mucous Digested foods Undigested foods Milk curd Bile Bright red blood Dark brown blood (coffee grounds) 4
5 . ~...: 7. Is there hunger right after vomiting? 8. Is swallowing difficult or painful?. F- Growth 1. Has there been weight loss? 2. Has there been a loss of appetite? 3. Has there been a change in eating habits?, G- Psychosocial 1. Has the problem Interfered with school, relatjonshlps orothel' activities? 2. Have there been stresses Involving (please circle): School Newhol.!se Home New babysitter or school Family births or deaths Problems with peers Parental conflict Separation or divorce Other 3. Has there been any physical or sexual abuse? " 4. Have there been problems with schoolwork? s. Has your child been to counseling before? If yes, please describe: 5
2. Have your symptoms affected your ability to carry out your daily activities? YES NO
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New Patient Health History Questionnaire Name: Today s Date: Address: City State, Zip Code Email Address: Date of Birth: Home Telephone #: Cell Number: Work Number: Emergency Contact name & number: Referred
General Internal Medicine Clinic - New Patient Questionnaire
Internal Medicine Associates of Southern New Jersey Robert Schwartz. D.O. University Executive Campus Marc H. Mlchelson. D.O., FAC.O.I. 151 Fries Mill Road,.Suite 400 James C.D'Amico, D.O. Turnersville,
History of Present Illness Please answer the following questions
Last Name First Name Date of Birth: / / What is the main reason for your visit today? Social Security Number: History of Present Illness Please answer the following questions Bladder Cancer Urinary Tract
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Email Address: Date of Birth: Marital Status: Married Separated Divorced
34th St. and Civic Center Blvd, Philadelphia, PA 19104, phone
34th St. and Civic Center Blvd, Philadelphia, PA 19104, phone 215-590-3630 www.chop.edu/gastroenterology Please complete this form prior to your child s visit. Please fax to (215) 590-7224 or e-mail it
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By