New Patient History New Patient History Today's Date(Required) MM slash DD slash YYYY Phone(Required)Email Patient Name(Required) First Last Birthdate(Required) MM slash DD slash YYYY ProblemsAre there any potential stress issues in your home?Select all that apply:(Required) None Alcoholism Chronic illness Disability Domestic violence Drug use Financial difficulties Marital difficulties Mental issues Recent death in the family Unsafe neighborhood AllergiesPlease list your child’s allergies (if any):Medications Add RemoveFoods Add RemoveSeasonal Add RemovePets Add RemoveOther Add RemoveMedicationsDoes your child take any medications? (please include vitamins and herbal)(Required) Yes No If yes, please list all below: Add RemoveImmunizationsHas your child received immunizations?(Required) Yes, up to date. Behind on immunizations. No, none. If child is behind, please list what shots and why below: Add RemovePast Medical HistoryPlease check all that apply:(Required) None Serious injuries or accidents Surgeries Hospitalizations Chicken Pox Frequent Ear Infections Problems with ears and or hearing Asthma, Bronchitis, Pneumonia Animals Outdoor Allergens Indoor Allergens Heart problems or Heart Murmur Anemia or Bleeding Problem Blood Transfusion Frequent Abdominal Pain Constipation Requiring Doctor Visits Bladder or Kidney Infection Bed-wetting (after 5 years of age) If female, have menstrual periods started? If female, any problems with period? Chronic or recurrent skin problems (acne, eczema, etc.) Frequent Headaches Convulsions or Other Neurological Problems Diabetes Thyroid or Other Endocrine Problems Use of Alcohol or Drugs Other Significant Problems If you child has been hospitalized overnight since birth, when and for what reason?If your child has had any surgeries, when and for what reason?Are there any specialists who take care of your child (i.e. allergist, ENT)? Who and for what reason?Comments on any other items selected above:Social HistoryWho does the child live with?(Required)Both ParentsMotherFatherRelativeGuardianParents are:(Required)MarriedDivorcedSeparatedSingleIf parents are not together, what is the custody arrangement?Please list the names, sex and age of siblings. Also, if full, half, step or adoptiveNameSexAgeRelation Add RemoveDo you have pets in the home?(Required) Yes No If yes, please list all pets: Add RemoveDoes anyone smoke in the home?(Required) Father Mother Sibling Caregiver Other * Please select all that apply.Guns in the home?(Required) Yes No If yes, are guns locked/secured? Yes No If yes, is the gun stored separately from ammunition? Yes No Home LifeWhat kind of home does the child live in? House Apartment Condo Shelter Other If other, please specify below: Was your home built before 1970?(Required) Yes No If yes, have you done any major remodeling to cover or remove old lead paint? Yes No Do parents work? If yes, please list occupation.(Required) Yes No Occupation(s)Father/GuardianMother/Guardian Add RemoveDoes your home have any of the following: None Smoke Detectors Carbon Monoxide Detectors Pool Hot Tub Nearby lake, pond, or stream Childcare/EducationDoes your child go to daycare?(Required) Yes No If yes, is the daycare provider a: Relative Before/After School Program Nanny/Sitter in your home Licensed Daycare Center Private Home, Licensed Private Home, Unlicensed Does your child go to school?(Required) Yes No If yes, please list school name and grade. (*If child is homeschooled please list under school name.)School NameGrade Add RemovePerinatal HistoryAssigned sex at birth:(Required)MaleFemaleWhere was the child born:(Required) Child’s birth weight:(Required) Was the child premature?(Required) Yes No If yes, how many weeks early? Any problems during pregnancy?(Required) Yes No If yes, please explain:How was baby delivered?(Required) Vaginally C-section Were there any problems during delivery?Did baby need any special help after delivery?(Required) Yes No If yes, please check all that apply: Oxygen Jaundice lights Antibiotics Other If other, please specify below: CAPTCHA
