PEDIATRIC MEDICAL HISTORY AGE 12-17 Date: __________
Patient’s Name:______________________ Date of Birth:_________
SOCIAL HISTORY: Please check all that apply to your child in the following categories:
Tobacco use?
□ No Tobacco Use □ Never
□ Cigarettes
□ Pipe/Cigar
□ Chew
□ Secondhand Smoke
If you smoke or have smoked how many packs smoked/day?____________ Total years smoked?_____________
Considered tobacco cessation counseling?
□ Not Considered Quitting
□ Considering Quitting
Alcohol use? □ None □ In Recovery □ Occasional
Drug use?
□ None □ Current Use
Drug use details: □ Cocaine
□ Heroin
□ Quit Date Established ___________________
□ One Drink/Day □ Binge
□ More Than One Drink/Day
□ Previous Use
□ Designer/Club
□ Hallucinogens
□ Narcotics
□ Opiates
□ Inhalants
□ Marijuana
□ Sedatives
□ Amphetamines
CURRENT SYMPTOMS:
Describe your child’s major symptoms or reason for your visit today:__________________________________________
How long have the symptoms been present?_________________________ Have you had allergy testing? □ Yes
□ No
What makes the symptoms better or worse?_______________________________________________________________
What treatments have been tried so far?__________________________________________________________________
What tests have been performed (e.g. Labs, X-Rays)?_______________________________________________________
Please check any symptoms your child is currently experiencing or have recently experienced:
Please check any symptoms you believe your child is currently experiencing or has recently experienced:
General:
Ears:
Throat:
Respiratory:
□ Fever
□ Hearing Loss
□ Recent Voice Change
□ Cough
□ Weight Loss
□ Ringing in Ears
□ Difficulty Breathing
□ Shortness of Breath
□ Weight Gain
□ Night Sweats
□ Ear Pain
□ Ear Drainage
□ Difficulty Swallowing
□ Can’t Clear Throat
□ Wheezing
□ Noisy Breathing
□ Loss of Appetite
□ Ear Fullness
□ Chronic Cough
□ Snoring
Nose:
□ Dizziness
□ Hoarseness
Gastrointestional:
□ Obstruction/Congestion
□ Post Nasal Drip
Hematologic:
□ Abnormal Bleeding
□ Sore Throat
□ Loss of Taste
□ Nausea
□ Vomiting
□ Drainage/Pus
□ On Blood Thinners
Psychiatric:
□ Reflux/Heartburn
□ Loss of Smell
Endocrine:
□ Depression
Neurologic:
Cardiovascular:
□ Chest Pain
□ Heat Intolerance
□ Cold Intolerance
□ Anxiety
□ Insomnia
□ Numbness
□ Weakness
□ Heart Palpitations
□ Diabetes
Musculoskeletal:
□ Headaches
□ Extremity Edema
□ Excessive Thirst
□ Joint Pain
□ Blood Clots
□ Joint Swelling
□ Arthritis
9399 Crown Crest Blvd., Suite 401, Parker, CO 80138
Office: 720-274-2544
Fax: 720-274-2541
Patient’s Name:_____________________________ Date of Birth:_____________
PAST MEDICAL HISTORY: Please check all diagnoses that apply to your child:
□ No Major Medical History
General History:
Respiratory:
Autoimmune:
Cardiac:
□ Chronic Fatique
□ Asthma
□ Lupus
□ Angina
□ Chronic Pain
□ COPD
□ Raynauds
□ Atrial Fibrillation
□ Fibromyalgia
□ Pneumonia
□ Rheumatoid Arthritis
□ Heart Failure
□ Long Term Steroid Use
□ Allergies/Hay Fever
□ Scleroderma
□ High Cholesterol
□ Obesity
□ Respiratory Failure
Gastrointestional:
□ High Blood Pressure
□ Anemia
Endocrine/Metabolic:
□ GERD
□ Endocarditis
Ears/Nose/Throat:
□ Vitamin D Deficiency
□ Ulcers
□ Heart Attack
□ Hearing Loss
□ Diabetes Type 1
□ Cirrhoisis
□ Coronary Artery Disease
□ Polyps Nasal/Sinus
□ Diabetes Type 2
□ Colitis/Crohn’s
□ Heart Valve Disease
□ Recurrent Ear Infections
□ Hyperthyroidism
□ Hernia
Vascular:
□ Recurrent Sinusitis
□ Hypothyroidism
Neurologic:
□ CVA/Stroke
□ Vertigo
□ Thyroid Cyst
□ Autism
□ Transient Ishemic Attack
Eyes:
□ Thyroid Nodule
□ Developmental Delay
□ Pulmonary Embolism
□ Glaucoma
□ Graves Diseaase
□ Seizures
□ Aneurysm
□ Retinal Detachment
Infectious Diease:
Genetic/Congenital:
□ Abdominal Aortic Aneurysm
□ Macular Degeneration
□ Hepatitis ____
□ Cleft Palate
□ Deep Vein Thrombosis
□ Cataracts
□ AIDS
□ Down Syndrome
□ Peripheral Artery Disease
Allergies:
□ HIV
Cancer:
□ Venous Insufficiency
□ Food
Sleep:
□ Skin/Melanoma
Events:
□ Seasonal
□ Apnea
□ Thyroid
□ Concussion
□ Animal
□ CPAP
□ Gastrointestional
□ Head Injury
□ Environmental
□ Insomnia
□ Oral
□ Trauma
□ Other Past Medical History________________________________________________________________________
_________________________________________________________________________________________________
PAST SURGICAL HISTORY: Please list any surgeries and dates:
□ No Surgical History
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Patient’s Name:_____________________________ Date of Birth:_____________
FAMILY MEDICAL HISTORY: Please list any pertinent family history. For example; cardiac, respiratory, cancer, etc.
Alcoholism
Asthma
Blood clots
Cancers
Heart disease
Colon cancer
Dementia
Diabetes
High cholesterol
High blood pressure
Kidney disease
Liver disease
Breast cancer
Stroke
Lung disease
Mental Health
Other
Daughter
Son
Sister
Brother
□ Family History Unknown
Father
Document the age of
onset in the box for
the appropriate
disease and family
member.
Mother
□ No Pertinent Family History
Patient’s Name:_____________________________ Date of Birth:_____________
DEPRESSION SCREENING:
In the past 2 week have you felt either of the following:
Little interest or pleasure?
□ Yes, in the past 2 weeks
□ No
Down/Depressed/Hopeless?
□ Yes, in the past 2 weeks
□ No
MEDICATIONS:
Does your have any medication or medical allergies?
□ Yes
□ No
If yes, please list the allergy, date of diagnosis and type of allergic reaction you have:
Drug/Medical allergy
Allergic Reaction
____________________
_____________________________________________________________________
____________________
_____________________________________________________________________
____________________
_____________________________________________________________________
____________________
_____________________________________________________________________
____________________
_____________________________________________________________________
____________________
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Please list all PRESCRIBED AND OVER-THE-COUNTER MEDICATIONS including vitamins and minerals below:
□ I currently take NO medication
Medication Name
Dosage and how many times per day medication is taken
____________________
________________________________________________________________________
____________________
________________________________________________________________________
____________________
________________________________________________________________________
____________________
________________________________________________________________________
____________________
________________________________________________________________________
____________________
________________________________________________________________________
PHARMACY INFORMATION:
Local Pharmacy of Choice:______________________________________Telephone#:(_____)_____________________
Local Pharmacy Location:____________________________________________________________________________
Street Address or Cross Streets
City
State
Zip
Mail Order Pharmacy: ______________________________________Telephone#:(_____)________________________
Pharmacy Location: _________________________________________________________________________________
Street Address or Cross Streets
City
State
Zip