Pediatric - Patient Information Form

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Pediatric - Patient Information Form

UNIVERSITY OF VIRGINIA HEALTH SYSTEM

PEDIATRIC SURGERY

Patient History Form

 

 

Patient Name:  __________________________________     Birthdate:  __/__/____      Sex:  M __  F __

SSN:  ____-___-_____      Referred by: ____________________________       Phone:_______________________

Pediatrician/Family Doctor:  _____________________________________      Phone:_______________________

Mother:  __________________________________ Phone: ____________ Call Intercept? Y / N   Code ____

Address:  _____________________________________________________________________________________

Father:  ___________________________________ Phone: ____________Call Intercept? Y / N   Code ____

Address:  ____________________________________________________________________________

Legal Guardian (if other than parent) _______________________________________________________   

Phone: ____________________________________________________________

Address:  ____________________________________________________________________________

Siblings (names and ages): ____________________________________________________________________________________

Parents are:           Married ____         Single ____        Separated ____        Divorced ____

Pets in home: _____________________________________________________                                               

Smokers in home ______________________________________________________________________

 

Special  Diet Needs_____________________________________________________________________________

 

Home Health Provider _________________________________________________________________   

Phone _____________________________________________________________________________

 

School Name ___________________________________________________    Grade ________________

 

List Allergies (medicine, food, asthma, hayfever, latex, etc.)  ____________________________________________

_____________________________________________________________________________________________

 

Current Medications (List any that the patient is taking (including over the counter meds herbal, vitamins):)

Name of Medicine:

How Much

How Often

Name of Medicine:

How Much

How Often

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth History

Length of pregnancy __________________               Type of delivery  ___ Vaginal         ___C-Section       ___Induced 

 

Was patient premature?  ____Yes   ____No                 If yes, in what week of gestation was patient born?  ________

 

What was the patient’s birth weight?  ___________

 

Describe any complications the patient had immediately after birth _______________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

 

 

Immunizations

Is patient current on all required immunizations?  _______Yes   ________No

 

 

 

 

Family History (mother, father, brother, sister, grandparents, aunts, and/or uncles)

CONDITION

YES

NO

CONDITION

YES

NO

Diabetes

 

 

Hirschsprung’s Disease

 

 

Heart disease

 

 

Cystic fibrosis

 

 

High blood pressure

 

 

Seizures

 

 

High cholesterol

 

 

Kidney disease

 

 

Cancer (if yes, specify type)

 

 

Pyloric stenosis

 

 

Blood disorder

 

 

Bowel blockage

 

 

Sickle cell trait

 

 

Inflammatory bowel disease

 

 

Allergic disease

 

 

Biliary atresia

 

 

Asthma

 

 

Tracheoesophageal fistula

 

 

Tuberculosis

 

 

HIV/AIDS

 

 

Drug/substance use

 

 

Venereal disease

 

 

Other hereditary disease

 

 

 

 

 

 

 

 

 

 

 

 

Past Medical/Surgical History

 

YES

NO

Comments

Surgeries (if so, please list)

 

 

 

 

 

 

 

Hospitalization (if so, please list)

 

 

 

 

 

 

 

Accidents/Injuries (if so, please list)

 

 

 

 

 

 

 

If patient is a girl, has she started her menstrual period?

 

 

If yes, specify date of last menstrual period:

Age at first menstrual period:

 

Review of Medical Problems (check all that apply)

 

Headache

 

Hyperactive

 

Trouble feeding

 

Dizziness/light-headedness

 

Impulsive

 

Reflux/vomiting

 

Vision problems

 

Inattentive

 

Constipation

 

Hearing problems

 

Aggressive behavior

 

Loss of bowel control

 

Memory loss

 

Compulsive or routine oriented

 

Excessive gas

 

Speech difficulty

 

Urinary tract infection

 

Rash

 

Blackout/fainting

 

Seizures

 

Birth marks

 

Jaundice/yellow skin

 

Infections

 

Abnormal skin growth

 

Heat intolerance

 

Wheezing

 

Unexplained fevers

 

Cold intolerance

 

Asthma

 

Weight loss

 

Excessive thirst

 

Breathing difficulty

 

Weight gain

 

Cranky/fussy

 

Blue spells

 

Chronic pain

 

Bleeding Problems

 

Heart conditions

 

Impaired mobility

 

Depression

 

Chest pain

 

Other:

 

 

Completed by: ____________________________________________            

Date: _______________________________

Relationship to patient: _____________________________________