34th St. and Civic Center Blvd, Philadelphia, PA 19104, phone
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1 34th St. and Civic Center Blvd, Philadelphia, PA 19104, phone Please complete this form prior to your child s visit. Please fax to (215) or it back to us at CHOPGIAccess@ .chop.edu before your child s appointment. Please bring the original form with you when you come for your first visit. This provides us with information about your child s health and past medical history. Today s date: GI appointment date: Child s name: Date of birth: Sex: M F Person completing this form: Relationship to child: Who referred you to us? What other doctors does your child see? Pediatrician Information Name: Address: Other Specialists Name & Specialty: Address: Telephone: Name & Specialty: Address: Telephone: Name & Specialty: Address: Telephone: Telephone: What are the concerns that bring your child to the GI doctor? abdominal pain constipation weight loss vomiting blood in stool abnormal lab results reflux loose stool/diarrhea jaundice choking accidents with stool poor growth feeding difficulty liver disease other (specify) Page 1 of 8
2 Does y our child have any known allergies? Allergies Name of Food or Medication What was the reaction? Drugs Latex X-ray dyes Blood products Foods Please tell us if your child has any of the following conditions listed below: G6PD deficiency Don t know Malignant hyperthermia Don t know Ketogenic diet Don t know Prolonged QT Don t know Does your child need pre-medications or antibiotics before dental procedures or surgery? Don t know If yes, explain: Please list your child s current medications (including over the counter medication, vitamins and supplements): Medication Dose/Strength How often? Directions for use Page 2 of 8
3 Pregnancy and Birth History (Answer only if your child is less than 8 years) Were there any complications during pregnancy? If yes, check the ones that apply: Gestational Diabetes Elevated blood pressure Pre-eclampsia Pre-term contractions Meconium aspiration Polyhydramnios (extra amniotic fluid) Other How many weeks into pregnancy (Gestational age) was your baby delivered? : weeks How was the baby delivered? vaginal vacuum/forceps assist Cesarean - If Cesarean, why? Baby s Birth weight: lbs oz Birth length: inches Any complications with your baby at birth? If yes, check the ones that apply: Jaundice requiring phototherapy Other Was your baby in the NICU? If yes, why? If yes, how long was your baby in the NICU? When did your baby have the first bowel movement (meconium) Before hours old Greater than 72 hours t sure Did your baby ever drink formula? If yes, what brand (s) of formula? Immunization History of your child Are your child s immunizations up to date? If no, why? Has your child ever been admitted to a hospital (excluding ER visit)? If yes, please explain When? Which hospital? Reason for Admission? MD/CRNP notes Page 3 of 8
4 Please enter your child s past medical and past surgical history. If you answer yes, please explain symptoms or diagnosis in the box provided. Please check the box that applies to your child GI ENT Lungs Heart Nervous System Endocrine Urology : Psychology Past Medical History Surgical History ne MD/CRNP notes Page 4 of 8
5 Family/Social History Who lives at home with the patient? Names and ages of brothers and sisters? Does your child go to? Day Care Medical Day Care Head Start School Preschool Kindergarten Grade Other How is your child s attendance at school? Has your child s behavior or grades at school been affected? Please let us know how. Do you have any pets? If so, what kind? Any recent travel outside of the tri state area? Home water supply? Well City Does anyone smoke around your child? Does your child smoke? Family ancestry/ethnic background (check all that apply): Asian/Pacific Islander Black/African American Hispanic/Latino Native American Indian White/Caucasian Other Page 5 of 8
6 Family Medical History Dad s height: ft in Mom s height: ft in Please check ( ) the boxes that apply to your child and relatives. Abdominal pain Allergy Asthma Celiac disease Chronic diarrhea Colon Cancer Constipation Crohn s disease/ibd Cystic Fibrosis Gastroesophageal reflux (GERD) Hirschsprung s disease Irritable Bowel Syndrome (IBS) Migraine/Headaches Pancreatitis Polyps Thyroid disease Ulcers Ulcerative colitis (IBD) Liver disease Gallstones Jaundice Hepatitis Cirrhosis Sister Name- Brother Name- Biological mother Biological father Maternal grandmother Maternal grandfather Paternal grandmother Paternal grandfather Other (please specify) Page 6 of 8
7 Review of Systems If there are symptoms, please complete by checking the box (s) or writing it in the spacing provided. General rmal fever excessive sweating fatigue exercise intolerance excess weight gain weight loss, how much poor appetite feeling full after eating a small amount Skin rmal eczema dry skin acne bruising hair loss itching jaundice lumps/bumps Eyes: rmal glasses contact lenses light sensitivity Ears, se & Throat: rmal hearing Loss snoring ear infections sinus infections sleep apnea tonsillitis tooth decay mouth sores Kidney: rmal kidney failure urinary tract infections bedwetting Blood circulation: rmal Anemia sickle cell disease sickle cell trait thalassemia trait bleeding tendency Development: rmal global delay motor delay sensory delay speech delay PT OT speech therapy early intervention autism spectrum disorder Asperger s syndrome Respiratory: rmal asthma/wheezing pneumonia persistent Cough pneumonia (more than 1 or 2) Immunology: rmal Musculoskeletal system: rmal bone problems back problems joint problems muscle pain mobility issues Psychology issues: rmal ADHD OCD bipolar depression behavior issues anxiety Endocrine: rmal diabetes adrenal problems hypothyroidism hyperthyroidism obesity menstrual periods (if applicable) Age when periods started: cycles - regular irregular Cardiovascular: rmal heart problems heart surgery hypertension congenital heart disease Neurology: rmal headaches hydrocephalus seizures cerebral palsy Page 7 of 8
8 Diet History If your child is an infant/toddler, please answer the following questions: Is your child currently breast fed? If breastfed, how many feedings per day? Type of formula: Quantity of formula per bottle Number of feeds per day: Other foods: If your child is older than a toddler, please answer the following questions: How would you describe your child s diet? normal diet for age special diet, if so please explain: Any diet restrictions? If yes, please explain: Is your child is on tube feedings? If yes, please answer the following questions: Is your child allowed to eat by mouth? If not, please explain the reason: aspiration risk other What is the type of tube feeding? NG tube G tube J tube What formula do you currently use? Please explain the feeding schedule: bolus feeds: How many times/day? How many mls run over how much time?. continuous feeds: mls run over at a rate of mls/hour from to. Has your child had any tests done for his current GI problem? If yes, please list tests below and bring copies of these results with you to your child s appointment. Please tell us anything else you think may be important for us to know about your child. Staff initials and date: Page 8 of 8
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PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care
What do you feel are your child s strengths at this time?
PEDIATRIC MEDICAL QUESTIONNAIRE Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully
Date of Birth: Age: Sex: male female. Weight: Height: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s
*All information provided is kept in strict confidence Child s Name: Date: Date of Birth: Age: Sex: male female Weight: Height: Girls: Age at first period: Address: Parents: Mother s Phone: (home) (cell)
Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX Phone (903) Fax (903)
Ebele C. Chira, MD 1055 Clarksville Street, Suite 190, Paris, TX 75460 Phone (903) 905-4609 Fax (903) 905-4611 Enclosed are forms for you to complete prior to your appointment. Please bring these completed
Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
Pediatric Intake Form Thank you for taking the time to fill out this form. This information is very important in order to best assess your child s needs. Patient s Name: Birthdate: (dd/mm/yyyy) Mother`s
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work