Pediatric - New Patient Health History Form

ADVERTISEMENT

PEDIATRIC - New Patient Health History Form
(patient under age 13)
Last Name _______________________ First Name ________________________ M.I. ________
Date of Birth: ___/___/_____
Sex: M F
Home Phone: (____)______________
Alt Phone: (____)_______________
If you would like us to send your ongoing medical records to another physician, please list them:
Family Doctor: ___________________
Referring Doctor: ________________________ Other Doctor: __________________
Have you been seen by any of the physicians at Capital Otolaryngology? Yes No
Has a member of your family been seen by any of the physicians at Capital Otolaryngology? Yes (specify) _________ No
How did you hear about us? (please circle): Doctor Referral Internet Yellow Pages
Insurance Friend
Other ___________
Reason for today’s visit: ______________________________________________________________________
___________________________________________________________________________________________
Have you had any tests, scans (CT or MRI), or treatments for this problem: Yes No
If yes, what was done and which doctor ordered them: ___________________________________
Answer all questions
All responses are confidential
1. MEDICAL HISTORY
Height_________ Weight _________
5. ALLERGIES (write ‘none’ if you have no known allergies)
a.
Please list any drug allergies________________
2.
_______________________________________
PLEASE LIST ANY HEALTH CONDITIONS/ILLNESSES:
_______________________________________
b. Please list any seasonal allergies or food
_______________________________________
allergies:________________________________
_______________________________________
_______________________________________
____________________________________
6. FAMILY HEALTH HISTORY
a.
Please list any pertinent family medical
3. SURGICAL HISTORY
conditions (and relation to patient)
Please list any surgeries/hospitalizations you have had
_______________________________________
(please include date)? ____________________________
_______________________________________
______________________________________________
_______________________________________
______________________________________________
b. Does anyone in the household where the child
resides smoke?
YES
NO
4. MEDICATIONS
Please list all medications you take (include prescription
& over-the-counter medications):
7. PHARMACY: (Name, Location, Phone #)
Med
Dosage Frequency
______________________________________________
__________________
______ ________
______________________________________________
__________________
______ ________
__________________
______ ________
__________________
______ ________
__________________
______ ________
X
Patient/Guardian Signature
Print name
Date

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

New Patient Health History Form New Patient Health History Form Medical
New Patient Health History Form New Patient Health History Form Medical
Form Rfmc 212 - Patient Health History Form Form Rfmc 212 - Patient Health History Form Medical
Patient Health History Form Patient Health History Form Medical
Patient Health History Form Patient Health History Form Medical
Patient Health History Form Patient Health History Form Medical
New Patient Medical History Form New Patient Medical History Form Medical
New Patient Medical History Form New Patient Medical History Form Medical
New Patient & Medical History Form New Patient & Medical History Form Medical
New Patient Medical History Form New Patient Medical History Form Medical

Related Categories

Parent category: Medical
Download
Go