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PEDIATRIC PATIENT INTRODUCTION CHILD’S NAME: ________________________________ MOTHER’S NAME: Last First Middle __________________________________ Last AHC NUMBER: _________________________________ FATHERS NAME: First ____________________________________ Last ADDRESS: _____________________________________ CITY/TOWN: Middle First Middle ________________________________________ PROV:__________________ POSTAL CODE:___________________ HOME PHONE: ____________________________ MOTHER’S WORK PHONE: _____________________ FATHERS WORK PHONE: _______________________________ EMAIL: __________________________ EMAIL REMINDERS: Y__N__ BIRTHDATE (DD/MM/YY): ______________ AGE: ________ SEX: ________ # OF SIBLINGS: ____________ TYPE OF BIRTH: _____ VAGINAL BIRTH WEIGHT: ____________ BIRTH LENGTH: ___________ _____ CESAREAN CURRENT WEIGHT: _ __________ CURRENT LENGTH: _____FORCEPS _________ _____BREECH PREGNANCYHISTORY:________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ LABOUR AND DELIVERY HISTORY: ____________________________________________________________________ ______________________________________________________________________________________________________ _____________________________________________ _____________________________________________________ APGAR SCORES: _________/_________ WAS THERE PRESENCE AT BIRTH OF: ______ JAUNDICE (YELLOW) ______ CYANOSIS (BLUE) CONGENITAL ANOMOLIES/DEFECTS:___________________________________________________________________ INFANT FEEDING: ____BREAST #OF HOURS SLEEP PER NIGHT: _____ __ ____BOTTLE ____FORMULA QUALITY OF SLEEP: ____GOOD ____FAIR ____POOR OBSTETRICIAN/MIDWIFE: (Name) ___________________________ (Located at) ___ _______________________________ PEDIATRICIAN/FAMILY MD: (Name) __________________________ (Located at) _________________________________ DATE OF LAST VISIT TO MD: _________________ PURPOSE OF VISIT: __ ___________________________________ IMMUNIZATION HISTORY: ____________________________________________________________________________ PURPOSE OF THIS APPOINTMENT: _____________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ HAS YOUR CHILD EVER BEEN TREATED ON AN EMERGENCY BASIS: ________________ ____________________ DESCRIBE: ______________________________________________________________ ____________________________ PEDIATRIC CASE HISTORY DEVELOPMENTAL HISTORY: AT WHAT AGE DID THIS CHILD: Follow an object with his/her eyes ______ Respond to sound _______ Crawl _________________________ Stand _____________ Hold head up ______ Sit alone_________ Walk alone _________ HAS THIS CHILD EVER SUFFERED FROM: Neonate/Infant Problems Orthopedic Problems: Neurological: ⧠ Head Shape Concerns ⧠ Neck Problems ⧠ Headaches ⧠ Head Position/Favouring ⧠ Backaches ⧠ Dizziness ⧠ Breastfeeding Difficulties ⧠ Low Back Problems ⧠ Fainting ⧠ Hip Concerns ⧠ Arm Problems ⧠ Behavioural Problems ⧠ Leg/Feet Concerns ⧠ Leg Problems ⧠ ADD/ADHD ⧠ Digestion Concerns ⧠ Feet/Ankle Problems ⧠ Paralysis ⧠ Shoulder/Arm Concerns ⧠ Growing Pains ⧠ Seizures ⧠ Clavicle Concerns ⧠ Gait/Walking Concerns ⧠ Genetic Syndrome ⧠ Erb’s Palsy CHILDHOOD DISEASES: ⧠ Chicken pox ⧠ Mumps ⧠ Measles ⧠ Rubella ⧠ Rubeola ⧠ Other:________________ General: ⧠ Allergies ⧠ Asthma ⧠ Recurrent ear infection ⧠ Stomach aches ⧠ Constipation ⧠ Diarrhea ⧠ Rupture/Hernias ⧠ Heart Problems ⧠ Diabetes ⧠ Whooping Cough _______________________________________DO NOT WRITE BELOW LINE____________________________________ PREGNANCY HISTORY:________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ DELIVERY HISTORY:__________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ PRESENT HISTORY:____________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ SURGERY:____________________________________________________________________________________________ MEDICATIONS:________________________________________________________________________________________ ACCIDENTS:____ ______________________________________________________________________________________ FAMILY HISTORY:_____________________________________________________________________________________
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