Download Pediatric Endocrine Associates, MassGeneral Hospital for Children

NEW PATIENT INFORMATION Pediatric Endocrine Associates, MassGeneral Hospital for Children Suite 6C, Yawkey Outpatient Center, MGH Office Phone 617­726­2909; Fax 617­724­0581 Note: Your filling out this form will help to make your child’s initial evaluation more comprehensive. Please be assured that the relevant information will be reviewed with you during the visit. Patient Name: __________________________________________ Date of Birth: __________________________________________ Primary Care Provider: __________________________________________ Other Providers to Receive Reports: __________________________________________ __________________________________________ Reason for Endocrine Evaluation: __________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Pregnancy and Birth History: Birth Weight: ______________ Birth Length:______________ Complications of Pregnancy:
• Early Bleeding
• Illness or Prescribed Medication
• Diabetes
• High Blood Pressure
• Illicit Drug Use
• Smoking
• Other Comments: ___________________ Delivery and Nursery Stay:
• Born at term (± 3 weeks of due date)
• Pre­term (more then 3 weeks early)
• Post­term (more then 3 weeks late)
• Vaginal Delivery
• Caesarian Section
• Prolonged Nursery Stay _______________________________ _______________________________ _______________________________ _______________________________ Comments: ___________________ Developmental History: Do you or your pediatrician have any concerns? YES NO •
• Comments: ________________________________________________________________ ____________________________________________________________________________
NEW PATIENT INFORMATION Pediatric Endocrine Associates, MassGeneral Hospital for Children Page 2 of 4 Hospitalizations: (if Yes, please provide details) YES NO • • Age or Year Reason for Admission __________ _________________________________________________ __________ _________________________________________________ __________ _________________________________________________ Major Illnesses: (if Yes, please provide details) YES NO • • Age or Year Illness/Treatment __________ _________________________________________________ __________ _________________________________________________ __________ _________________________________________________ Regular Medications: (if Yes, please provide details) YES NO Medication Condition being Treated Dose & Frequency _________________ ___________________ ___________________ _________________ ___________________ ___________________ _________________ ___________________ ___________________ _________________ ___________________ ___________________ _________________ ___________________ ___________________ Allergies: (if Yes, please provide details) • • YES NO • • Drug Allergies ____________________________________________ Food Allergies ____________________________________________ Environmental Allergies ____________________________________________ Other (example: latex) ____________________________________________ Significant Trauma or Injury: (if Yes, please provide details) YES NO • • Fractures ____________________________________________ Head Injury/Concussion ____________________________________________ Other ____________________________________________
NEW PATIENT INFORMATION Pediatric Endocrine Associates, MassGeneral Hospital for Children Page 3 of 4 Health Review: Check those that are (or have been) a concern; circle specific issues.
• Systemic problems fatigue, weight loss, weight gain, change in appetite, increased thirst, feeling unusually cold or warm
• Neurological problems frequent or severe headaches, seizures or convulsions, other
• Vision problems near­sighted, far­sighted, other
• Hearing problems
• Heart problems heart murmur, chest pain, palpitations, other
Additional Comments: • Breathing problems asthma, bronchitis, other
• Gastrointestinal problems constipation, diarrhea, hepatitis, abdominal pain, nausea, other
• Urinary problems history of UTI, frequent urination, burning during urination, kidney stones, recent bed wetting, other
• Skin problems rashes, eczema, pigmented lesions, other
• Bone or Joint problems swollen joints, multiple fractures, other ______________________________________________________ Family Health History Immediate Family Age Medical Problems (see list below) Mother _____ ____________________________________ Father _____ ____________________________________ Brother/Sister (circle one) _____ ____________________________________ Brother/ Sister (circle one) _____ ____________________________________ Brother/ Sister (circle one) _____ ____________________________________ Medical Conditions in Extended Family Persons Affected (relationship to patient; example: maternal grandfather) Diabetes ________________________________________________ ________________________________________________ Thyroid Disease ________________________________________________ Calcium Problems ________________________________________________ Other Hormone Problems ________________________________________________ ________________________________________________ Cancer (specify type) ________________________________________________ ________________________________________________ Heart Disease/Stroke under 50y ________________________________________________ Other Medical Problems ________________________________________________ ________________________________________________
NEW PATIENT INFORMATION Pediatric Endocrine Associates, MassGeneral Hospital for Children Page 4 of 4 Social History YES NO • • Are both parents in the home?
Comment: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Mother’s Occupation: __________________________________________________ Father’s Occupation: __________________________________________________ Child’s Information: Level in school: __________________________________________________ Typical grades: __________________________________________________ Favorite activities: __________________________________________________ __________________________________________________ __________________________________________________ Form filled out by: Name __________________________________________________ Relationship to patient __________________________________________________ Date __________________________________________________ Thank You!