Patient Name: DOB: Prenatal Exposure: None Alcohol Drugs Tobacco Other NICU Stay? Yes No *If yes, please specify reason and length of stay
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1 Patient Name: DOB: Patient Birth History Delivery Type: Vaginal C-section Premature Term Over Due Complications with delivery? Yes No *If yes, please describe: Birth Weight: pounds ounces Birth Height: Gestational age: weeks days Discharge weight: pounds ounces Prenatal Exposure: None Alcohol Drugs Tobacco Other NICU Stay? Yes No *If yes, please specify reason and length of stay Any Hospital stays other than birth? Yes No *If yes, specify age of hospitalization, reason and length of stay Patient History- Please circle all that apply: HEENT (Head, Ears, Eyes, Nose, Throat) History of Allergic Rhinitis Laryngomalacia Recurrent sore throat Brachial cleft anomaly Recurrent ear infections Tracheomalacia Cleft lip Cleft palate Recurrent sinusitis Other HEENT: Respiratory Allergies/hay fever Bronchitis Reactive Airway disease Apnea prematurity Croup RSV Asthma Esophageal atresia Bronchiolitis Pneumonia Endocrine Diabetes Mellitus Hyperthyroidism Hypothyroidism History of signs of early puberty Graves Disease Other: Cardiovascular Cardiac Arrest Congenital Heart Disease Pulmonary Hypertension Cardiac arrhythmia Heart Valve Diseases
2 Gastrointestinal Constipation GERD Jaundice Chronic Diarrhea Hepatitis Gallstones Feeding Difficulties Intussusceptions Genitourinary Night time wetting Kidney failure Daytime wetting Hydronephrosis Past UTI Inguinal hernia UPJ Obstruction Umbilical hernia VU reflux Other: Gynecological (Females only) Age at first menstrual cycle STD Other known conditions: Hematology Abnormal bleeding Nose bleeds Transfusion Musculoskeletal Congenital Hip Dysplasia Fractures Juvenile Rheumatoid Arthritis Rotator Cuff Tear Scoliosis Cancer Blood cancer Brain cancer Leukemia Musculoskeletal cancer Infectious Disease Chickenpox Chlamydia HIV MRSA Meningitis Pertussis Integumentary (skin) Acne Psoriasis Sunburn Eczema Problems with healing Sunburn with blistering HSP Keloids Neurologic Cerebral palsy Headaches Seizures Developmental delay Hydrocephalus TBI Epilepsy Mental retardation Fetal alcohol syndrome Psychiatric ADD ADHD Behavior Problems Learning Problems Bulimia Anorexia Mood disorders Cyclothymiacs Pervasive development Anxiety Depression Schizoaffective disorder Aspergers disorder Dysthymic Autism Homicidal
3 Genetic/Metabolic Birth defects Cystic fibrosis Obesity Chromosomal disorder Down Syndrome Congenital deformity Failure to Thrive Other Genetic: Other Metabolic: Events: Anaphylaxis Disabilities Hearing deficit Paraplegia Vision deficit Hemiparesis Quadriplegia Other: HEENT (head, ears, eyes, nose, throat) Adenoidectomy Lacrimal duct probing Brachial cleft excision Lasik eye surgery Cleft palate repair Ear tubes Tonsillectomy DC thyroglossal excision Tracheotomy Dental surgery Respiratory Bronchoscopy Esophageal dilation TE Fistula repair Chest tube Lung biopsy Thoracotomy Con. diaphragm hernia repair Lung resection Decortication Cardiovascular Ablation Heart transplant Pericardial window Cardioversion NUSS/Ravitech Valve replacement Congenital heart defect revision PDA ligation Patient Surgical History Please circle all that apply Yes: NO: Gastrointestinal Appendectomy Gastrostomy tube PH probe Cholecystectomy GT change PSARP Colectomy Ileostomy Pyloric stenosis repair Colonoscopy Inguinal hernia repair Reduction of intussusceptions Colostomy Jejunostomy tube Small bowel Endorectal pullthrough LADDS procedure Splenectomy Endoscopy Lobotomy Umbilical hernia repair Gastroschisis repair Nissen fundoplication VY cutback Gastrostomy closure PEG tube
4 Surgical history continued Genitourinary Anoscopy Nephrectomy Urethral reimplanation DEFLUX procedure Rectal biopsy Fusulectomy Rectal dilation Circumcision (males only) Other: Musculoskeletal Club foot repair Rotator cuff repair Fracture repair Other: Neurologic Craniotomy Spinal surgery VP shunt revision VP shunt placement Meningomyelocele repair _ Endocrine Parathyroidectomy Thyroid surgery Thyroidectomy Integumentary (skin) Cystic hygroma excision Implant placed Scar revision Dermoid excision Implant removed Umbilical hernia repair Hernia repair-ventral I&D Pilomatrixoma excision Lymphatic Node biopsy Node excision Other: Please list parents and siblings names and birth dates in the space provided below. -please tell us if siblings are male or female, as names can be unisex. -Please circle those who live in the household with the child. -If parents are separated, please indicate who lives in each household. Parent s occupations: Mom: Dad: Do you have any pets? If so, please list. Is the patient exposed to secondhand smoke? Yes No
5 Family History Please circle positive conditions regarding the patient s parents, siblings and grandparents. Indicate the individual affected by the condition and the age of diagnosis if known. (Ex: Diabetes mellitus: maternal grandmother, years of age) Adverse reaction to anesthesia Alcohol abuse Anemia Asthma Autoimmune disorder Blood disorders Breast cancer Colon cancer Congenital anomaly Congestive heart failure Coronary artery disease Dementia Depression Diabetes Mellitus Drug abuse Eczema Gastric/stomach cancer Genetic disorder Hardening of arteries Heart attack Hearing problems High blood pressure High cholesterol Kidney cancer Kidney disease Learning disability Liver disease Malignant hyperthermia Mental disorder Obesity Ovarian cancer Pancreatic cancer Prostate cancer Rheumatoid arthritis Seizures Skin cancer Stroke Thyroid disease Tobacco abuse Tuberculosis Uterine cancer Vision disorders
Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
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