New Patient Past Medical History Form printable pdf download

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New Patient Past Medical History Form

Please complete this form before your appointment. Because sleep is affected by any body system, and by environmental

and social issues, we need comprehensive information to adequately evaluate sleep problems. Thank you for your time.

General Information

Name: _______________________________________ DOB: ___________ Age: ____________ Date: _________________

Person filling out form: ____________________________________Relationship to Patient:__________________________

Referring Physician: ____________________________________________________________________________________

Other physicians to receive report, and their fax #s:__________________________________________________________

Main reason for visit today:_____________________________________________________________________________

How long has this problem been present? ________________ How severe? (circle one)

mild

moderate

severe

Past Medical History (

Please circle the appropriate response)

Full Term (≥ 37 weeks)

Birth History:

Premature (# of weeks:___________)

Hospitalizations: None

Dates and reasons: ___________________________________________________

Surgeries: None

Tonsillectomy (Date: __________)

Adenoidectomy (Date: ____________)

Ear tubes (Date: ___________)

Other: __________________________________________________________________________________

Immunizations:

Up to date: No

Yes

Flu shot this season: No

Yes

Allergies to medications:

Yes

(If yes, list medication and reactions): _________________________________

Does the patient smoke?

Yes

(Please write amount, how often, and write if taken only “as needed”)

Current Medications / Supplements

Not currently taking any medications

Name

Strength / Dose

Frequency (how often)

Other therapies:

Please circle and write settings if applicable

CPAP

BiPAP

Oxygen

Ventilator

Other

Settings: ___________________________________________________________________________________________________

Review of Systems (

Please circle the correct responses)

General Health

Good

Sleepy

Always tired

Appetite: Good

Poor

Weight: Normal

Under

Over

Genetic syndrome:

Skin

Normal

Dry Eczema Itching at night

Eyes

Normal

Glasses Nearsighted Farsighted

Visual Impairment

Ears, Nose, Throat

Normal

Ear infections

Hearing loss Stuffy nose Runny nose Post-nasal drip

Sinus infection Mouth breathing while awake Mouth breathing while asleep

Enlarged adenoids Enlarged tonsils Frequent strep throat

Neck

Normal

Stiffness

Swollen Glands

Tracheostomy

Respiratory

Normal

Asthma Cough

Wheezing

Shortness of breath

Stops breathing

Cardiovascular

Normal

Heart Murmur Congenital Heart Defect Heart failure Fainting Hypertension

Gastrointestinal

Normal

Diarrhea

Constipation

Vomiting

Heartburn

Spits up GE Reflux

G-tube

Genitourinary

Normal

Bedwetting

painful urination

bladder infection

Musculoskeletal

Normal

Scoliosis

Back pain

Arthritis

Neurological

Normal

Headaches

Seizures

Weakness Developmental Delay

Hypotonia

Psychiatric/Behavioral Normal

Behavior problems

ADHD

ADD

Anxiety

Depression

Autism

Endocrine

Normal

Diabetes

Hypothyroidism

Hematology

Normal

Anemia

Immunodeficiency

Other:

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Patient Name: _____________________________ Date ______________

P e d i a t r i c a n d A d o l e s c e n t S l e e p C e n t e r , a d i v i s i o n o f F a i r f a x N e o n a t a l A s s o c i a t e s , P C

New Patient Past Medical History Form

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