ࡱ>  'bjbj $~̟̟d d ''''';@@@87A$[A4;L0BB"BBBCCCKKKKKKK1MOzK'CCCCCKD''BBKDDDC"'B'BKDCKDD''DpH˻@C^D0DtK0LDMPDMPDD'DCCC;;)@;;@d :   PEDIATRIC GASTROENTEROLGY HEPATOLOGY & NUTRITION CLINIC New Patient History Form (Please fill out this form and bring it with you to your appointment) CHILDS NAME:______________________PRIMARY DOCTOR: ________________ PHARMACY you want to use: Name:_______________________________________ Street: ______________________________________City: ____________________________ Why are you bringing your child to the GI clinic?________________________ When did the problem start? __________________________________________________ How often does the problem occur?__________________________________________ FAMILY HISTORY: (Circle ALL that apply) Does ANYONE in the family have the following illnesses on mother or fathers side, Including parents, siblings, first cousins, grandparents, aunts or uncles, etc.? SEIZURES, MIGRAINES, HEART ATTACKS/DISEASE, STROKE, ASTHMA, ECZEMA, ALLERGIES, HIGHBLOOD PRESSURE, THYROID DISORDER, DIABETES, ULCERS, GALL STONES, ULCERATIVE COLITIS, CROHNS DISEASE, MISCARRIAGES, GASTROINTESTINALSURGERY, POOR GROWTH, POOR WEIGHT GAIN, SUDDEN INFANT DEATH SYNDROME, APNEA, DIARRHEA, CELIAC DISEASE, LIVER PROBLEMS, KIDNEY PROBLEMS, BLEEDING PROBLEMS, LACTOSE INTOLERANCE, CONSTIPATION, HEARTBURN (REFLUX), COLON CANCER, ESOPHAGEAL CANCER, AND OTHER CANCERS (list types), OTHER ILLNESSES? _____________________________________________________________________________ AGES & SEX OF BROTHERS AND SISTERS: _____________________________________________________________________________ MOTHERS PAST MEDICAL HISTORY WITH THIS CHILD: Any problems during pregnancy with this child: (Bleeding, infection, premature labor, medications taken during pregnancy, other): ______________________________________________________________________________ Any problems during delivery? (Premature, infection, Cesarean, resuscitation, other) _______________________________________________________________________________ Any problems in the nursery? (Jaundice, infection, not passing stool, other) ______________________________________________________________________________ Patients birth weight: ______________ PATIENTS PAST HOSPITALIZATIONS & SURGERIES: Reason Date Name & Location of Hospital ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ PATIENTS SIGNIFICANT ILLNESSES: (Circle & explain ALL that apply) Heart problems, Lung problems, Bladder/kidney infection, Seizures, Cancer, Blood pressure problems, Bleeding problems, Asthma, Seasonal allergies, Mental illness, ADD, ADHD, Others (list below) If patient is female: Date patients periods first started? _______________________ Are they regular (circle)? Yes / No DEVELOPMENTAL HISTORY OF CHILD: Normal ____________ Delayed __________ TRANSFUSION HISTORY: Has your child received any blood products? Yes/No DIET HISTORY: Does your child eat the following? Sugarless gum or sugarless candy (circle)? Yes/ No/ Unknown Fruit juice, non-diet soda, sports drinks. Does child consume greater than 8oz a day of those types of drinks frequently (circle)? Yes/ No/ Unknown Dairy products (circle)? Yes/ No/ Unknown ;Ounces per day consumed____________ Fruit or vegetables: 5 or more per day (circle)? Yes/ No/ Unknown Fluid (not including milk): Greater than 1 quart per day (circle)? Yes/ No/ Unknown Type of drinking water (circle)? : Well /Bottled /City Ground fresh water exposure; i.e. exposure to lakes, rivers, streams, etc. (circle)? Yes / No Is your child is on a special diet (circle)? Yes/No Low cholesterol, Gluten free, Lactose free, Other________________________________________________________ DIET: Please indicate the formula your child is on, how many ounces your child takes at a time, and how many times per day the formula is taken. Also, indicate the amount of water or juice your child takes per day. Please indicate whether your child can be orally fed or takes their feedings by gastrostomy tube. (Example: 8oz Pediasure 4 times a day. 1oz water 4 times a day). ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ SOCIAL HISTORY: Childs grade in school: _________ Performance (circle): good /average/poor Who lives with child? ________________________________________________________ Does child have friends (circle)? Yes/ No/ Unknown Stressful events at school (circle)? Yes/ No/ Unknown (explain) Stressful events at home (circle)? Yes/ No/ Unknown (explain) Smoking or chewing tobacco by child (circle)? Yes/ No/ Unknown Drugs or alcohol use by child (circle)? Yes/ No/ Unknown Tattoos or piercing of child (circle)? Yes/ No/ Unknown Is child sexually active (Circle)? Yes/ No/ Unknown Mothers Occupation_____________________Fathers Occupation________________________ Marital status of childs parents (circle)? Married, Separated, Divorced, Single, Widowed Childs Animal/Pet exposure (Dogs, cats, birds, etc.)? ________________________________ Travel outside the state (circle)? Yes /No Date: ____________ Location: _______________ MEDICATIONS: Please list all the medications your child is on, the dosage, and the number of times per day your child takes the medication. (If there are a number of medications, you may copy the medication list and staple list to this page). Please remember to write down the milligrams of the tablet or capsule your child is on or milligram/milliliter or the liquid of the medication your child is on. (Dont forget vitamins, herbal medications, inhaled medications, and medicated ointments) __________________________________________ ________________________________ __________________________________________ ________________________________ PLEASE CHECK ANY OF THE FOLLOWING SYMPTOMS YOUR CHILD HAS OR HAS HAD RECENTLY GENERALYESNOHEADYES NOTirednessFrequent sore throat or hoarsenessFeverFrequent cavitiesDecreased activityVisual or hearing problemsDecreased appetiteFrequent ear or sinus infectionsMissing schoolMouth soresPoor weight gain/weight lossSwallowing problemsExcessive weight gainRetching/gagging/chokingPoor sleepingPain on swallowingIrritability/Increased cryingFood getting stuck after swallowing CHESTYESNONERVOUS SYSTEMYESNOStopped breathingSeizuresTurned blueDepressionShortness of breathChange in personalityCoughAnxiousWheezingHeadachePneumoniaDifficulty with schoolBronchitisDizzinessChest pain GASTROINTESTINALYESNOKIDNEYS/BLADDER/REPRODUCTIONYESNOAbdominal bloatingPain on urinationAbdominal painFrequent urinationNauseaBlood in urine/Dark urineVomitingIrregular or painful periodsDiarrheaDischarge from penis or vaginaConstipationBONES/MUSCLES/JOINTSVomiting bloodJoint painBlood in the stoolJoint swellingBlack stoolBack painPale stoolSKINExcessive burpingRashExcessive gasBruises or bleeds easilyRegurgitationEczema Please list other physicians following your child so that we can send them a letter and update them on your childs progress. Please indicate whether your child is being followed by other agencies such as, CCS, CVRC, Home Health Nursing, etc. ________________________________________________________________ IMMUNIZATIONS UP TO DATE: Yes/No ALLERGIES TO MEDICATIONS: (Please list medications and reactions): _________________________________________________________________ Signature: ______________Relationship to child: __________Date: _________ Revised 12/09 PAGE  PAGE 1 8Sy a o  b*24R|1GH[=?Jw}Rc"2ZjhVJh]5hVJh]56 hQh] hAsh]h22Ih]56 h]5hbh]5h]hL:h]5hb}h]5G9S' x z  _ a / 1 , z H7`bgd]b^4|3]Jdgd]dQRc4v/iN;$a$gd]gd].Xh ( ) E F x y !!;!666666666666666666666666666666666666666666666666hH666666666666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH @`@ mNormalCJ_HaJmH sH tH V@V D Heading 1$$@&a$5CJOJPJQJ^JaJP@P D Heading 2$@&5CJOJPJQJ^JaJVV D Heading 3$$@&a$5CJOJPJQJ^JaJDA`D Default Paragraph FontRi@R Table Normal4 l4a (k ( No List PP DHeading 1 Char5CJOJPJQJ^JaJPP DHeading 2 Char5CJOJPJQJ^JaJPP DHeading 3 Char5CJOJPJQJ^JaJH>"H DTitle$a$5CJOJPJQJ^JaJH1H D Title Char5CJOJPJQJ^JaJLBBL D Body Text$a$CJOJPJQJ^JaJLQL DBody Text CharCJOJPJQJ^JaJ4 @b4 q0Footer  !.q. q0 Footer Char.)@. q0 Page NumberPK!K[Content_Types].xmlj0Eжr(΢]yl#!MB;BQޏaLSWyҟ^@ Lz]__CdR{`L=r85v&mQ뉑8ICX=H"Z=&JCjwA`.Â?U~YkG/̷x3%o3t\&@w!H'"v0PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!\theme/theme/theme1.xmlYOoE#F{o'NDuر i-q;N3' G$$DAč*iEP~wq4;{o?g^;N:$BR64Mvsi-@R4Œ mUb V*XX! cyg$w.Q "@oWL8*Bycjđ0蠦r,[LC9VbX*x_yuoBL͐u_. 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