NEW PATIENT FORM - OU Medicine

More documents

Recommendations

Info

Health History Patient______________________________________ Date_______________________ Reason for visit: _______________________________________________________________________ _____________________________________________________________________________________ Date symptoms first occurred ____________________________________________________________ Are symptoms continuous? Yes _____ No______ If NO please list dates and details: _________________________________________________________ _____________________________________________________________________________________ Please list any blood work done or tests previously performed: _________________________________ _____________________________________________________________________________________ Please have the following Information below available at your next appointment Current Medications Dosage Time Given _______________________________ __________ ___________________ _______________________________ __________ ___________________ _______________________________ __________ ___________________ _______________________________ __________ ___________________ Past Medication tired for present condition: ________________________________________________ Was Child hospitalized for above condition?: ________________________________________________ PAST MEDICAL HISTORY Is this child yours by: Birth_______ Adoption: _______ Step child_______ Other________ PREGNANCY Mother’s totally # of pregnancies_______ Number of Living Children _______ Mother’s total # of Abortions_______ Number of Miscarriages_________ Pregnancy with this patient was Normal? Yes _______ No _______ If NO please explain ____________________________________________________________________ _____________________________________________________________________________________ Were any drugs or medications used during the Pregnancy? Yes_______ No_______ If YES please list________________________________________________________________________ BIRTH HISTORY Birth Wt______ Birth Length ______ APGAR SCORES_____ _____ Length of Pregnancy_______ Type of delivery: Vaginal____ C-Section____ Planned____ Emergency _____ Did child have any complications during or immediately following birth: Yes___ No _____ If YES Please explain _____________________________________________________________ ______________________________________________________________________________ Developmental Milestones
Age child rolled over___________________ Spoke first words______________________ Sat up _____________________________ spoke in sentences____________________ Crawled_______________________ Potty trained_________________________ Cruised_______________________ Walked_____________________________ Is your child’s social development normal: Yes___ No___ If NO please describe (introverted, extroverted, aggressive, etc.)______________________________________________________ ______________________________________________________________________________ Is your child’s educational development normal? Yes____ No ___ If NO please describe (Regular ed., Special ed. etc) _______________________________________________________ ______________________________________________________________________________ Is your child physical development normal? Yes_____ No______ If NO please describe (fine motor skills, walking, running, etc.)_________________________________________________ ______________________________________________________________________________ Medical History Medical Date of onset Anemia ___________ Hydrocephalus ____________ Arthritis ___________ Leukemia ____________ Asthma ___________ Meningitis ____________ Bleeding Disorders ___________ Migraines ____________ Cerebral Palsy ___________ Pneumonia ____________ Concussion ___________ Psychology history ____________ Congenital heart Abnormality___________ Seizures ____________ Diabetes ___________ Skeletal Disorders ____________ Growth Abnormalities ___________ Other ____________ Hospitalizations/ Operations (with age)______________________________________________ Family Members Health History Does anyone in your family have or have a history of Cardiac Disease _____________ Strokes ____________ Depression _____________ Seizures ___________ Drug Addiction _____________ Seizures with fever___________ Eye Disease _____________ Slow Development____________ Migraines _____________ Schizophrenia _____________ Manic Depression _____________ Panic Attacks ______________ Muscle Disease _____________ Violent Behavior _______________ Nerve Disease _____________ Review of Systems General YES COMMENTS
Page 1: NEW PATIENT FORM Please print in in
Page 5: Painful urination _____ ___________

NEW PATIENT FORM - OU Medicine

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?