Patient History Form Note: This is a confidential record and will be kept in your doctor’s office. Information contained here will not be released to anyone without your authorization to do so.Today's Date* MM slash DD slash YYYY Name* First Name Middle Name Last Name History of Present Illness*What is the main reason for your visit today?Location of Problem* Abdomen Back Bladder How long does the problem last?* 30 mins 1 hour Always there On a Scale of 1-10 with 10 being the most severe, choose the number that best describes the problem:* 1 2 3 4 5 6 7 8 9 10 Is anything else occurring at the same time?* Yes No Please explain what else is occurring:* Vomiting/diarrhea Fever Blood in urine When did you first notice the problem?* 7 days ago 2 weeks ago 1 month ago Is the problem constant or variable?* Always there Sometimes there, sometimes not Does anything help or make the problem worse?Does the problem interfere with your child's normal functions?* Yes No Please explain how it interferes:*Past medical, family & social historyPast medical history:Current medications:Does patient have any medication allergies?* Yes No Please explain allergies:*Pregnancy history for mother of patient:Term pregnancy:* Yes No How many weeks late?*Pregnancy:* Normal Abnormal Please explain how it was abnormal:* UTI Gestational diabetes Preeclampsia/toxemia Cervical insufficiency Prenatal ultrasounds:* Normal Abnormal If abnormal, please explain:* Hydronephrosis Polyhydramnios Oligohydramnios List any of the patient’s past surgeries or procedures and when they occurred:How many siblings does the patient have?*Do any of the siblings have health problems? Yes No Please explain what kind of health problems:*List all serious illnesses in your immediate family:Example: diabetes, kidney failure, dialysis, kidney transplant, etc.Social HistoryLives with parents?* Yes No Patient is adopted?* Yes No Patient is in foster care?* Yes No Married or divorced? Married Divorced Review of systems Does the patient now or has the patient had any recent problems related to the following systems?General Fever Chills Abnormal growth Abnormal development OtherSkin Rashes Continued itching Easy bruising OtherEyes Blurred vision Redness Pain OtherMuscle system Joint pain Back pain Muscle cramping OtherAllergies Hay fever Drug allergies Foods OtherEar/Nose/Throat/Mouth Ear infection Sore throat Sinus problems OtherNervous System Seizures Abnormal walking Abnormal coordination OtherKidney/Bladder Blood in urine Burning with urination Frequent urination OtherHormone system Excessive thirst Tired/sluggish Abnormal hair growth OtherLungs Wheezing Frequent cough Shortness of breath OtherStomach/Intestines Stomach pain Nausea/vomiting Constipation OtherBlood/Lymph Glands Swollen glands Blood clotting problems OtherHeart Heart murmer High blood pressure OtherCommentsThis field is for validation purposes and should be left unchanged. Δ
