Pediatric - Patient Information Form

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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):)

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)

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: _____________________________________