Child And Pediatric Health History Form Page 4
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4MRN:
UNIVERSITY OF MICHIGAN HOSPITALS & HEALTH CENTERS
NAME:
Gastroenterology
BIRTHDATE:
Health History Questionnaire - New Patient
-Gastroenterology
CSN:
Review of Systems Please check any current problems / symptoms you have experienced in the last 2 weeks:
☐activity change
☐appetite change
☐chills
☐excessive sweating
Constitutional
☐fatigue
☐fever
☐unexpected weight change
☐hearing loss ☐nosebleeds ☐postnasal drip ☐dental problem
Ears, nose, mouth,
throat and face
☐mouth sores ☐trouble swallowing
☐eye redness ☐visual disturbance
Eyes
☐stop breathing at night
☐chest tightness
☐choking
☐cough
Respiratory
☐shortness of breath
☐wheezing
☐chest pain
☐leg swelling
☐palpitations (racing heart beats)
Cardiovascular
☐abdominal distention
☐abdominal pain
☐blood in stool
☐heartburn
Gastrointestinal
☐liver problems ☐constipation
☐diarrhea
☐nausea
☐rectal pain
☐vomiting
☐difficulty urinating
☐kidney stones
☐dysuria (painful urination)
Genitourinary
☐enuresis (incontinence)
☐flank pain
☐blood in urine
☐menstrual problem
☐pelvic pain
☐vaginal bleeding
☐vaginal discharge
Female Patients Only
☐vaginal pain
☐penile discharge
☐scrotal swelling
☐testicular pain
Male Patients Only
☐joint pain
☐back pain
☐gait problem
☐joint swelling
☐muscle weakness
Musculoskeletal
☐color change
☐rash
☐wound
Skin
☐dizziness
☐headaches
☐light-headedness
☐numbness
☐seizures
Neurologic
☐speech difficulty
☐fainting
☐tremors
☐weakness
☐confusion
☐swollen lymph nodes
☐bleeds/bruises easily
Hematologic (blood)
☐agitation
☐behavior problem
☐decreased concentration
Behavioral/Psychological
☐nervous / anxious
☐self-injury
☐sleep disturbance
☐suicidal thoughts
_____________________________________________________
_____/_____/________ (mm/dd/yyyy)
Printed name of person who completed this form
Date
FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART.
DISCARD FORM AFTER ENTRY, USING CONFIDENTIAL RECYCLE. DO NOT SEND TO HIM.
Page 4 of 4
Health History Questionnaire - New Patient
VER: A/12
50-10079
Do Not File
HIM: 08/12
- Gastroenterology
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