Download PATIENT`S

PATIENT’S NAME____________________________________________ SEX __ MALE __ FEMALE
AGE_________ DATE OF BIRTH_______________________ RACE ___________________________________
BIRTH HISTORY
BIRTH WEIGHT___________LBS ________OZ BIRTH HOSPITAL___________________________________
BIRTH CITY/STATE_________________ WERE THERE ANY COMPLICATIONS WITH THE PREGNANCY?
__ YES __ NO IF YES, WHAT?___________________________________________________________________
DID YOU HAVE A VAGINAL DELIVERY OR A C-SECTION? __________________________________________
IF C-SECTION WHY? _____________________________________________________________________________
WERE THERE ANY COMPLICATIONS WITH THE LABOR OR DELIVERY?
__ YES __ NO
IF YES, WHAT WERE THE COMPLICATIONS?
_________________________________________________________________________________________________
WERE THERE ANY PROBLEMS WITH THE BABY IN THE NURSERY?
__ YES __ NO
IF YES, WHAT WERE THE COMPLICATIONS?
_________________________________________________________________________________________________
WAS YOUR CHILD JAUNDICED IN THE NEWBORN PERIOD?
__ YES __ NO
DID YOUR CHILD RECEIVE THE HEPATITIS B VACCINE? __ YES __ NO DATE SHOT GIVEN__________
DID YOU
__ SMOKE, __ DRINK, OR __ USE DRUGS
DURING THE PREGNANCY?
TYPES OF DRUGS USED ___________________________________________________________________________
IS YOUR CHILD ALLERGIC TO ANYTHING INCLUDING MEDICINE?
__ YES __ NO
IF SO, WHAT? _____________________________________________________________________________________
CIRCLE THE CHILDHOOD DISEASES YOUR CHILD HAS HAD.
CHICKEN POX MEASLES MUMPS GERMAN MEASLES(RUBELLA) WHOOPING COUGH
SCARLET FEVER MENINGITIS(WHAT TYPE?) _________________________________
TETANUS
STREP THROAT
ARE YOUR CHILD’S IMMUNIZATIONS UP TO DATE?
__ YES __ NO
(PLEASE PROVIDE A COPY OF THE SHOT RECORD)
LIST ANY FOODS YOUR CHILD CANNOT TOLERATE. ___________________________________________________
LIST ANY PREVIOUS HOSPITALIZATIONS. _____________________________________________________________
LIST ANY PREVIOUS SURGERY. _______________________________________________________________________
LIST ANY ILLNESS YOUR CHILD HAS HAD. ____________________________________________________________
LIST ANY BORKEN BONES YOUR CHILD HAS HAD. _____________________________________________________
CIRCLE ANY ILLNESSES THAT RUN IN THE FAMILY
ASTHMA* BIRTH DEFECTS* CANCER(TYPE?) ____________ * CERENRAL PALSY* ADD/ADHD*
DIABETES* HIGH BLOOD PRESSURE* HEART DISEASE* KIDNEY DISEASE* LUNG DISEASE*
MENTAL DISEASE(TYPE?)_______________*
SICKLE CELL ANEMIA OR TRAIT*
GASTROINTESTINAL DISEASE*
OTHER___________________________________________
IF THE PATIENT IS A GIRL, HAS SHE STARTED HER MENSTRUAL PERIODS YET?
AGE OF 1ST PERIOD _________________________.
__ YES __ NO
LIST YOUR CHILDREN AND THEIR AGES FROM OLDEST TO YOUNGEST
NAME _______________________________________ AGE________
SEX __ MALE __ FEMALE
NAME _______________________________________ AGE________
SEX __ MALE __ FEMALE
NAME _______________________________________ AGE________
SEX __ MALE __ FEMALE
NAME _______________________________________ AGE________
SEX __ MALE __ FEMALE
NAME _______________________________________ AGE________
SEX __ MALE __ FEMALE
HOW DID YOU FIND OUT ABOUT BROWNRIDGE PEDIATRICS? _____________________________________________
SIGNATURE OF PERSON COMPLETING FORM _____________________________________________________________