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