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PATIENT INTAKE HISTORY – COMPLETED BY PARENT or PATIENT
Name: ___________________________________________ DOB: ____________ Date: ____
Reason for visit: _____________________________________________________________________________
Allergies (medications, food, or environmental): ____________________________________ ______________________________________________________________________________
Current medications & doses (include prescriptions, over the counter medications, and natural/herbal remedies):

_____________________________________ _______________________________________

_____________________________________ _______________________________________

_____________________________________ _______________________________________

_____________________________________ _______________________________________

_____________________________________ _______________________________________

_____________________________________ _______________________________________
REVIEW OF SYSTEMS: Please indicate if your child has a history of any of the following signs, symptoms, or disease. A box that is unchecked indicates a NO response. MUST COMPLETE THIS SECTION AT EVERY VISIT.


Unexplained fevers

□ Always tired

□ Poor appetite

□ Weight loss

□ Poor growth

_____________________

Wears glasses or contacts

□ Bright lights bother eyes

_____________________

□ Poor hearing

□ Dizziness

□ Motion sickness

Frequent ear infections

□ Frequent bloody nose

□ Always congested

□ Frequent sore throat

□ Croupy breathing

Hoarse voice

□ Snores during sleep

____________________

□ High blood pressure

□ Unexplained rapid heart

rate

□ Chest pain



Heart murmur

□ Heart disease

□ Chronic cough

□ Coughing while asleep

□ Wheezing

□ Asthma


More than one pneumonia

□ Breathing difficulty in

Sleep

______________________



□ More than one urinary tract

infection

□ Bed wetting during sleep

□ Wetting pants during

daytime

□ Girls – delayed onset of



periods

□ Girls – very irregular

periods

□ History of venereal disease



________________________

□ Frequent joint pain

□ Unexplained joint swelling

Back pain

□ Bone pain

□ Frequent muscle cramps or

weakness

□ Unexplained skin rash

________________________

□ Always pale

□ Eczema


Initial that all unchecked boxes indicate a NO response ______

Birthmarks

□ Frequent hives

□ Always sick

□ Exposure to HIV/AIDS

____________________

□ Frequent headaches

□ History of seizures

Weakness

□ Delayed development

____________________

□ Is a worrier

□ Always anxious

□ Depressed

Sleeps poorly

□ Learning problems

□ Hyperactive

□ Excessive arguing

□ ? Anorexia nervosa

□ ? Bulimia

____________________

□ Heat or cold intolerance

□ Diabetes

□ Thyroid problems

□ Excessive eating

Overweight

___________________

□ Anemia

□ Easy bruising

□ Swollen glands


PAST MEDICAL HISTORY:

IF NO CHANGES SINCE LAST VISIT PLEASE INITIAL ________
Birth weight: _____ lbs _____ oz Full term: ____ Yes ____ No

If premature, how early? ______ weeks

Problems during pregnancy? If yes, please explain: ____________________________________ ______________________________________________________________________________

Formula changes during infancy: Yes No

Gastroesophageal reflux during infancy: Yes No

Developmental milestones (sitting, walking, talking, independent self care): Normal Delayed


Previous hospitalizations: _______________________________________________________ ______________________________________________________________________________

Previous surgeries: _____________________________________________________________ ______________________________________________________________________________
FAMILY HISTORY: Please check if there is a history in your family of any of the following disorders:

IF NO CHANGES SINCE LAST VISIT PLEASE INITIAL _________





YES

NO

WHO




YES

NO

WHO

Heart disease










Hepatitis










High blood pressure










Gallstones










High cholesterol










Pancreatitis










Diabetes










Chronic abdominal pain










Cystic fibrosis










Spastic colon










Celiac disease










Irritable bowel syndrome










Crohn’s disease










Colon polyps










Ulcerative colitis










Constipation










Stomach ulcers










Asthma










Reflux disease










Migraine headaches










Liver disease










Overweight










Cancer






















Are there any other problems that run in the family? ____________________________________
SOCIAL HISTORY:

Patient lives with:___ Both parents ____ Mother ___ Father ____ Grandparent ____ Relative ____ Foster parent

Are natural parents separated or divorced? _____ Yes _____ No

Number of brother and sisters: ________

What grade is the patient in? ________ Does the patient receive special education? ______

How is his/her school performance? ________________________________________________

How many school days has the patient missed this year because of his/her GI problem? _______

Please indicate of your child is exposed to ___ pets ___ cigarette smoke ___ camping ___ foreign travel

What is the water source at home? _____ city water _____ well water _____ bottled water

Please indicate if there are any of the following stresses in the family that could be triggering your child’s GI symptoms:



__________ Recent family move __________ Death of a family member, close friend, or pet

__________ New school __________ Chronic illness of a close family member

__________ Difficulty making friends __________ Problems with a sibling

__________ New sibling __________ Family financial problems

__________ Separation or divorce of parents

__________ Foster care




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