New Patient Questionnaire Pediatric Orthopaedic Surgery

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Transcription:

Page 1 of 5 New Patient Questionnaire Pediatric Orthopaedic Surgery First Name: Last Name: Middle: DOB: Height: Weight: Primary Care Physician/Pediatrician Name: Address: Phone Number: Chief Compliant What is the reason for your visit? When did this condition start? Please explain how this condition started: Since the problem was first noticed, is it: Better Worse Same Current Pain Level (no pain 0 10 highest): 0 1 2 3 4 5 6 7 8 9 10 4. 5. Medication Dose Frequency Dietary or Herbal Supplements Name Dose Frequency Allergy Reaction

Page 2 of 5 Medical History Please check box if Medical History is Negative (None Apply) Cardiovascular Pulmonary Musculoskeletal Neurological Circulation-Vascular Asthma Arthritis Cerebral Palsy Disorder Heart Murmur Chronic Bronchitis Fractures Developmental Delay Heart Problems Pneumonia Osteogenesis Imperfecta Dysautonomia Hypertension Head Injury Hydrocephalus Seizures Stroke Gastrointestinal Renal HEENT Endocrine Failure to Thrive Kidney Disease Chronic Ear Infection Diabetes Mellitus GERD Sleep Apnea-obstructive Hypoglycemia Liver Disease Tonsillitis Osteoporosis Ulcers (GI) Thyroid Disease Growth Hormone Hematology Oncology Immunological Rheumatic Diseases Anemia Cancer Allergies Juvenile Idiopathic Arthritis Anesthesia Chronic/Repeated Kawasaki Disease Complications Infection Blood Disorders Lupus Sickle Cell Anemia Lyme Disease Rheumatoid Arthritis Scleroderma Sjogren s Syndrome Uveitis Skin Psychiatric Communicable Disease Eczema ADD/ADHD Hepatitis A Autism Hepatitis B Behavioral Disorders Hepatitis C Depression HIV/AIDS Measles MRSA Infection Mumps Rubella Tuberculosis Varicella Surgical and Hospitalization History 4. 5. Previous Operation/Hospitalization Occurrence Date (approx.) Do you or a family member have a history of complications with anesthesia?

Page 3 of 5 Social History Who does the patient live with? (Please complete this section if over the age of 10) Are you a tobacco user? Do you use electronic nicotine delivery systems (e-cigarettes, vape-pens, etc.)? Do you consume alcohol? Do you use drugs? Are you sexually active? Female Patients Only Date (month and year) and Age of first menses: Date of last menses (monthly period): Are you currently pregnant, or do you think that you might be pregnant? Family History Are there any illnesses that run in the family (mother, father, brother, sister)? Arthritis Relation: Asthma Relation: Birth Defects Relation: Clotting Disorder Relation: Clubfoot Relation: Bleeding Disorder Relation: Hip Dysplasia Relation: Learning Disability Relation: Rheumatoid Arthritis Relation: SCFE Relation: Scoliosis Relation: Spine Disorder Relation: Other: Relation:

Page Page 4 of 4 of 5 5 Please list any and all additional healthcare providers: Specialty Name/Medical Group Phone Number Orthopedist Pulmonologist Neurologist 4. Cardiologist 5. Endocrinologist 6. Hematologist 7. Neurosurgeon 8. Rheumatologist 9. Physiatrist 10. Physical Therapist 1 Speech Therapist 1 Psychologist 1 Other: Review of Systems Please check box if entire Review of Systems is Negative (None Apply) Constitutional Hematologic Respiratory Skin Chills Easy bruising/bleeding Shortness of breath Hives Fever Clotting disorder Cough Rash Sleep disturbance Nose bleeding Wheezes Infections Fatigue Gum bleeding Upper resp. infection Night sweats Night pain ENT Cardiovascular Endocrine Musculoskeletal Vision problems Chest pain Weight loss Joint pain Hoarseness Palpitations Weight gain Joint swelling Snoring Poor circulation Leg weakness Arm weakness Back pain Gastrointestinal Genitourinary Neurological Psychiatric Bowel problems Urinary problems Coordination problems Anxiety Trouble swallowing Dizziness Mood swings Loss of appetite Blackouts Depression Nausea Loss of balance Vomiting Difficulty walking Diarrhea Headaches Eyes Environmental Allergies Other Dryness Pollen Discharge Dust Mites Itching Pets/Animals Pain Mold/Mildew Redness

Page 5 of 5 Please complete the Birth History and Developmental History sections only if child is < age 6, or if relevant to current orthopaedic problem. Birth History and Development Was the patient born prematurely? If yes, please specify the number of weeks the child was born: Indicate the patient s birth weight: Delivery Method: Vaginal Spontaneous Breech Forceps Vacuum (extractor) C-Section Classical Unspecified If child was born via C-Section, please indicate reason: Currently attending school? Receiving special education services? Enrolled in age appropriate grade level? Current grade level: Developmental Milestones/History Developmental History (please select): Development is Normal Global Developmental Delays Child first walked independently: Mild Developmental Delays Unknown Child first rolled over: Child first spoke 3 words: Child first sat unsupported: Educational grade level: Reviewed by: Nurse: Physician: Date: Date:

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