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* Date Format: 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*AbdomenBackBladderHow long does the problem last?*30 mins1 hourAlways thereOn a Scale of 1-10 with 10 being the most severe, choose the number that best describes the problem:*12345678910Is anything else occurring at the same time?*YesNoPlease explain what else is occurring:*Vomiting/diarrheaFeverBlood in urineWhen did you first notice the problem?*7 days ago2 weeks ago1 month agoIs the problem constant or variable?*Always thereSometimes there, sometimes notDoes anything help or make the problem worse?Does the problem interfere with your child's normal functions?*YesNoPlease explain how it interferes:*Past medical, family & social historyPast medical history:Current medications:Does patient have any medication allergies?*YesNoPlease explain allergies:*Pregnancy history for mother of patient:Term pregnancy:*YesNoHow many weeks late?*Pregnancy:*NormalAbnormalPlease explain how it was abnormal:*UTIGestational diabetesPreeclampsia/toxemiaCervical insufficiencyPrenatal ultrasounds:*NormalAbnormalIf abnormal, please explain:*HydronephrosisPolyhydramniosOligohydramniosList 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?YesNoPlease 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?*YesNoPatient is adopted?*YesNoPatient is in foster care?*YesNoMarried or divorced?MarriedDivorcedReview 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 OtherNameThis field is for validation purposes and should be left unchanged.
