child s last name: first name middle iditial: date of birth / /

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P E D I AT R I C PAT I E N T 1 child s last name: first name middle iditial: date of birth / / please answer all questions to the best of your knowledge. completion of this intake information is an essential part of your medical care. current medication name of medications route (i.e., by mouth, inhalation, injection) dosage frequency (i.e. once/ twice a day, as needed) length of time taking this medication prescribed medications over the counter medications herbal medications

P E D I AT R I C PAT I E N T S child s last name: 2 MEDICAL HISTORY 1) birth history: a) your child was born full term premature a) was there any tobacco, alcohol or drug useage/exposure during pregnancy? no yes b) describe any complications that may have occured during pregnancy: d) has your child ever been intubated? no yes e) describe any complications your child may have had during or immediately after birth: 2) nutrition history: a) please check the type(s) of feedings your child had in the first year of life: breast feeding from months to months old bottle feeding from months to months old please list formula names: solid food was introduced at months old b) please describe any adverse reactions your child may have experienced from feedings: vomiting diarrhea reflux colic constipation skin rashes hives other c) adverse reaction resolved by 3) check all conditions below with which your child has been diagnosed: croup _ ear infection pneumonia sinus infection skin infection/abscess chronic diarrhea infection of bone infection of blood

3 MEDICAL HISTORY continued meningitis _ 2) has your child had a blood transfusion in the past?: yes no reasons for tranfusion 3) please check all medical conditions that apply to your child: migraines glaucoma heart disease high blood pressure diabetes thyroid disease, low thyroid disease, high high cholesterol hepatitis a, b, or c tuberculosis sleep apnea osteoporosis rheumatoid arthritis sle/lupus autoimmune disease heart disease, please specify: neurological disorder, please specify: cancer, please specify: other conditions: 4) history of exposure to chicken pox: never had chicken pox vaccinated have had chicken pox 5) flu shot: receive flu shot yearly never received flu shot some years but not every year; last flu shot received was on ALLERGY HISTORY 1) has your child had reactions to the following? medications name of medication: others: name of medication: others:

4 MEDICAL HISTORY continued name of medication: others: foods type of food: others: foods type of food: others: foods type of food: others: insect stings type of insect: swelling at the sting site others:

5 MEDICAL HISTORY continued latex product type of product: others: radio-contrast media (iodine/dye) name of the contrast media: others: anesthetic agents name of medication: others:

6 SURGICAL HISTORY Please check all of your child s past surgeries: month/year of surgeries reasons adenoidectomy / appendectomy / back surgery / gall bladder removal / sinus surgery / tonsillectomy / pe tubes / other, please specify / HOSPITALIZATION please describe all of your child s past hospitalization(s): month/year of hospitalization reasons staying overnight in a hospital / / / emergency room visits / / /

7 FAMILY HISTORY mother father siblings child maternal maternal maternal maternal paternal paternal paternal paternal cousins grand grand aunts uncles grand grand aunts uncles mother father mother father alcoholism/drug allergy seasonal/ year round allergy anesthetic agent allergy, drug allergy, food allergy, insect sting allergy, latex arthritis asthma autoimmune disease birth defect blood disorder cancer cystic fibrosis diabetes eczema emphysema hay fever heart disease high blood pressure high cholesterol immuno-deficiency kidney disease liver/intestinal mental illness mental retardation migraines seizure disorder thyroid disorder tuberculosis other:(disease name)

8 SOCIAL HISTORY 1) smoking: never yes average pack per day of cigarettes: year started with smoking: year stopped smoking: determination to quit 2) recreational drug use: no yes 3) exercise 2-3 times per week on a regular basis: yes no 4) alcohol: no socially become intoxicated with alcohol never 2-3 times per year fewer than 6 times per year 6-10 times per year once a month or more 5) school: grade concerns regarding social/academic achievement no yes 6) daycare: no yes; how many days a week? IMMUNOTHERAPY HISTORY 1) has your child received allergy shots in the past? no yes a) year that your child first started on allergy shots: 199 200 b) last time your child received allergy shots: month: year: c) has your child had systemic reactions (i.e., full body hives, difficulty in breathing, including wheezing, ) to allergy shots? no yes ENVIRONMENT HISTORY 1) type of your child s current residence: house apartment mobile home condominium 2) age of your child s current residence: years old 3) location of your child s residence: urban rural farm 4) how long has your child lived in this residence? years 5) how long has your child lived in colorado? years 6) other state(s)/country where your child has lived: continued on next page

P E D I AT R I C PAT I E N T child s last name: 9 ENVIRONMENT HISTORY continued 7) the following questions pertain to detailed description of your residence: please check all that apply: a) basement: no basement crawl space completely finished partially finished unfinished basement flooring: carpeting hard surface both water damage: never water damage has been fixed current water damage has not been fixed b) possible mold exposure: none leaky roof visible moldy spots musty smell water damage that has been fixed professionally currently has water damage that has not been fixed c) hot tub: none outdoor indoor d) cooling system: air conditioner none swamp cooler e) heating system: gas electric hot water wood burning stove f) fireplace: none type of fireplace: gas wood frequency of use: never used fewer than three times per year more than three times per year used as a heat source g) humidifier: none type of humidifier: central portable frequency of use: never throughout the year throughout winter season only when a family member develops a cold other: h) air purification system: central hepa filter portable hepa filter none electronic filter ionic breeze other: i) flooring in your house: hard surface in the entire house carpeting throughout the house except kitchen and bathrooms carpeting in bedrooms only carpeting in bedrooms and living areas only other:

10 ENVIRONMENT HISTORY continued j) patient s bedroom: location of bedroom: main floor 1st floor 2nd floor basement flooring of bedroom: hard surface carpet age of mattress: < 5 years 5-10 years > 10 years age of pillows: < 5 years 5-10 years > 10 years allergen-proof covers: not used used for pillows used for mattress used for comforters box spring down bedding: none pillows comforter cleaning of pillowcase and sheet: once a week twice a month once a month < once a month use warm water use hot water cleaning of comforter: once a week twice a month once a month < once a month use warm water use hot water k) pets: none type of pets: dog(s) number of pet dog(s): cat(s) number of pet cat(s): rabbit(s) number of pet rabbit(s): guinea pig(s) number of guinea pig(s): hamster(s) number of hamster(s): bird(s) number of pet bird(s): other: number of pet animal(s): pets are kept: exclusively outdoors in the lower level and not allowed upstairs in the house but not allowed in patient s bedroom in the house and allowed in patient s bedroom l) exposure to cigarette smoke: none yes smokers: self parent(s) relatives co-workers places where exposure occurs: in the house in the car at work 8) please describe your occupational history: years start to finish job title job description 9) please list your and your child s hobbies:

P E D I AT R I C PAT I E N T child s last name: 11 REVIEW OF SYSTEM please check all symptoms that your child has experienced and/or is currently experiencing. constitutional weight loss weight gain loss of appetite fever night sweat fatigue difficulty falling asleep restless sleep headaches upon awakening on a regular basis excessive drowsiness during the daytime sleep disturbances difficulty gaining weight colic breast feeding formula feeding dermatology rash eczema dry or sensitive skin hives photosensitivity acne hair loss birthmarks nail abnormalities changes in color or size of moles allergy stuffy nose runny nose sneezing itchy watery eyes skin reaction to metals skin reaction to cosmetics skin reaction to chemical food allergy insect sting allergy latex allergy reaction to anesthetic agents ear, nose & throat hearing loss ringing in the ears ear pain dizziness nose bleed loss of taste or smell sensation facial pain stuffy nose runny nose sore throat snoring post nasal drip thrush bad breath hoarseness of voice ulcer in the mouth mouth breathing opthalmology itchy watery eyes seasonal eye symptoms eye irritation drainage from eyes diminished vision loss of vision double of vision blurring of vision respiratory wheeze chest tightness up blood chest pain noisy breathing exposure to tuberculosis nighttime exercise-induced more than 2 weeks with a cold symptoms cardiology chest pain heart murmur irregular heart beat racing heart beat leg swelling dizziness fainting varicose vein continued on next page

P E D I AT R I C PAT I E N T child s last name: 12 REVIEW OF SYSTEM continued gastroenterology difficulty swallowing nausea vomiting heartburns bloating abdominal pain constipation diarrhea change in bowel habits blood in stool urology/reproductive pregnant nursing recurrent kidney or bladder infection frequent urination at night unable to hold urine urinary urgency difficulty in urination abnormal urine stream blood in urine pain with urination female reproductive system abnormal periods cramps lasting longer than first few days of periods abnormal vaginal discharge endocrinology cold intolerance heat intolerance excessive appetite excessive thirst frequent urination at night abnormal development of facial/body hair musculoskeletal joint stiffness joint pain joint swelling back pain Osteoporosis muscle weakness or pain neurology headaches migraines memory loss dizziness double vision seizures stroke numbness abnormal balance muscle weakness developmental delay psychology depression mood swings concentration problems anxious high stress level sleep disturbances eating disorder mental or physical abuse suicidel ideations hematology swollen glands easy bruising difficult to stop bleeding anemia varicose veins Other:

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