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Microsoft word - med_history_form_children_v10.12.doc

Medical History Form v.10.12 – Children
The Ear Center of Greensboro, P.A., 1126 N. Church St., #201, Greensboro, NC 27401
(Please fill in the blank or circle the answer where appropriate)
Patient Name: ___________________________________ Age: ________ Date: ________
Sex: M or F Weight: __________ Height ___________
Ethnicity:
Non-Hispanic, Hispanic, Non-Specified Race: ___________________
Preferred Language: English, Spanish, Other: _____________________________________
CC: For what problem is your child being evaluated? _______________________________
Date started: ____________________________________________________________
Total number of infections or episodes?_______________________________________
Last infection or episodes: _________________________________________________
Symptoms: (Circle current symptoms)
Fussy, irritable, pain, poor sleeping, decreased appetite, others;____________________
Signs: (Circle if applicable)
Fever, drainage, perforation in eardrum
Treatment: (Circle antibiotics prescribed)
Amoxicillin, Augmentin, Ceftin, Omnicef, Septra, Suprax, Zithromax, Rocephin Injection,
Other medications:_____________________________________________________
Risk Factors:
Daycare: Yes or No Number of children in class? ______________________
Exposed to second hand smoke: Yes or No
Number of siblings: ____ Ages: _______ Siblings history of ear infections: Yes or No
Parent’s history of ear disease: ______________________________________________
Other Medical History: (Yes or No)
Previous tubes: _______________ Tonsil/adenoids removed: _________________
Cardiac problems: _____________ Respiratory problems: ____________________
Other Surgeries or problems: ________________________________________________
Birth History:
Full term: _________________ Weeks of Gestation: _____________________
Vaginal or C-Section: _______________ Complications: _________________________
Admittied to NICU? ________________For how long?__________________________
Were they placed on a ventilator? _____ Oxygen? ______________________________
Did they pass their newborn hearing screen? ___________________________________
Did they have yellow jaundice?________Were they treated with lights?_____________
Any genetic problems or syndromes? _________________________________________
Allergies:
What medications are they allergic to? ________________________________________
Any food allergies?_________________Any seasonal allergies?____________________
Other__________________________________________________________________
Speech and Language:
Responding to sounds: Yes or No Babbling: Yes or No
Number of words: _______ Putting two words together: Yes or No
Speaking in sentences: Yes or No
Can you understand them clearly: Yes or No
Anesthesia History:
List any family history of anesthesia problems: _________________________________ Fevers during anesthesia: Yes or No Prolonged wake-up time: Yes or No
Nausea or Vomiting: Yes or No Other problems with anesthesia: ___________
American Indian Heritage? Yes or No
Bleeding Disorders: (circle if applicable)
Family history of: Hemophilia, Sickle Cell Anemia, Anemia, easy bruising,
easy bleeding, others: _____________________________________________________ MD Initials:____

Source: http://earcentergreensboro.com/forms/documents/registration/MED_HISTORY_FORM_CHILDREN_v10.12.pdf

El camino

Jeg går i sommeren 2007 en 800km lang rute, som gås af pilgrimme fra hele verdenen. Ruten går gennem Nordspanien og slutter i Santiago de Compostello. Jeg har afsat 5 uger. Undervejs vil jeg blogge her på logiskhave. Arkiv for July 2007 Er ved at være klar til afrejse på fredag. Stivkrampevaccinatioen er i orden, det blå sygesikringsbevis er dog kun et forløbigt papir, men jeg re

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Divine Prozac: God’s Prescription for Worry and Anxiety We all struggle with our thoughts to one degree or another. For many people it is a constant battle to keep from becoming angry, frustrated, depressed, or worried. But in the midst of this battle, God has given us His Son, His Spirit, and His Word to fight these battles and to win them. He has also given us one specific passage of Script

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