Download extensive past medical social family history

FAMILY CARE HEALTH CENTERS
PEDIATRIC PATIENT HISTORY FORM
Name:
Last
First
Date:
Middle
Date of Birth:
Who is your doctor?
When were you last seen by your previous doctor?
MEDICAL
MEDICAL Hx
Y
N
Y
N
ALLERGIES
Allergic Rhinitis
Y
N
CANCER
Y
Y
Y
Y
Y
N
N
N
N
N
CARDIOVASCULAR
Murmur
Congenital
Cholesterol
Fainting (Syncope)
Y
Y
N
N
DERMATOLOGY
Eczema
Y
Y
Y
Y
N
N
N
N
ENDOCRINE
Diabetes Type I
Diabetes Type II
Thyroid Disorders
Y
Y
Y
Y
N
N
N
N
ENT
Recurrent Acute Otitis Media
Sinusitis
Hearing Loss
Y
Y
N
N
EYE
Degree of Visual Impairment
SURGICAL
SURGICAL Hx
Y
N Previous Surgery
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
GENETIC HISTORY
Y
Y
Y
N
N
N
INFECTIOUS DISEASE BACTERIAL
Methicillin-resistant Staph
Tuberculosis
GASTROINTESTINAL
GERD
Constipation
GYNECOLOGIC
HEMATOLOGIC
Anemia
Bleeding Disorders
Blood Transfusion
Sickle Cell Trait
IMMUNOLOGIC
INFECTIOUS DISEASE VIRAL
Hepatitis
HIV
Varicella
Y
Y
Y
Y
Y
N
N
N
N
N
NEUROLOGIC
Headaches
Febrile Seizure
Epilepsy
Developmental Delay
Y
Y
N
N
ORTHOPEDIC
Fracture
Y
Y
Y
N
N
N
PSYCHIATRIC
ADD/ADHD
Depression
Y
Y
N
N
RENAL
UTI
Y
Y
Y
N
N
N
RESPIRATORY
Asthma
Pneumonia
Y
N
RHEUMATOLOGIC
Y
Y
Free Text
Y
N
N
UROLOGIC
VU REFLUX
Other PMH
Y
Y
Y
N
N
N
Cardiothoracic Surgery
Heart Surgery
Lung Surgery
Y
Y
Y
N
N
N
Orthopedic Surgery
Knee Surgery
Hip Surgery
Y
N
Gastrointestinal Surgery
Y
N
Neurological Surgery
Y
Y
N
N
Y
N
Dermatological Surgery
Y
N
Abdominal Surgery
Appendectomy
Y
Ruptured
Inguinal Hernia Repair
Y
N
Kidney Surgery
Y
N
Head & Skull Surgery
Y
Y
Y
N
N
N
Eye Surgery
Nasolacimal Duct Probe
Strabismus Correction
Y
Y
N
N
Y
Y
N
N
Otolaryngologic Surgery
Ear Surgery
Myringotomy Tubes
Y
Adenoidectomy
Tonsillectomy
Y
N
Oral Surgery
Y
Y
N
N
Urologic Surgery
Circumcision
Y
N
NeckSurgery
Y
N
Testis Surgery
Free Text
Y
Other PMSH
FH
FAMILY MEDICAL HISTORY
Y
N Family History Unchanged
Y
N Family Health Status
Y
N Heart disease
Y
N Hypertension
Y
N High cholesterol
Y
N Diabetes
Y
N Cancer
Y
N Thyroid disorder
Y
N Kidney disease
Y
N Asthma
Y
N Emphysema
Y
N Cystic Fibrosis
Y
N Tuberculosis
Y
N Hepatitis
Free Text
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
Cimbosis
Ulcerative colitis
Crohn’s disease
Bleeding/clotting disorder
Immunodeficiency disorder
HIC Infection
Arthritis
Seizure disorder
Stroke
Neurologic disorders
Psychiatric
ADD
Birth defects
Family History (Free Test)
SOCIAL HISTORY
SOCIAL BACKGROUND
Lives with
Y
Parents – Married
Y
Mother
Y
Separated
Y
Divorced
Y
Joint Custody
Y
Sole Custody
Y
w/Stepfather
Y
w/Stepbrother
Y
w/Stepsister
ETHNIC BACKGROUND
Cultural Background
Y
Caucasian
Y
Hispanic
Y
African American
Y
Asian
Y
American Indian
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Father
Separated
Divorced
Joint Custody
Sole Custody
w/Stepmother
w/Stepbrother
w/Stepsister
Christian
Jewish
Muslim
Other
SMOKING EXPOSURE
Y
Father
Y
Y
Mother
Y
Y
Brother
Y
Y
Sister
Y
Y
N Exposure to second hand smoke
Free Text
Y
Social History
Y
Family History
Y
Y
Y
Y
Grandparent(s) in the home
Grandparent(s) as Guardian
Other Relative in the Home
Other Relative as Guardian
Native Language
Y
English
Y
Spanish
Y
Chinese
Y
Hindi
Y
Polish
Y
N
Difficulty w/English
Maternal Grandfather
Maternal Grandmother
Paternal Grandfather
Paternal Grandmother
HOME
Lives in
Y
Y
House
Apartment
OCCUPATION
Y
Father
Y
Mother
Y
Patient
PETS
Y
Y
Y
Y
Y
Y
Y
N
Pets in Home
Dog
Cat
Bird
Fish
Lizard/Turtle
Other Pet
SOCIAL HISTORY
Y
N
Social History Unchanged
Y
N
Alcohol Use
Y
N
Smoking
Y
N
Caffeine Use
Y
N
Drug Use
Y
N
Exercise Habits
Y
N
Sexually Active
Y
N
Contraception (current)