Patient's Name

Date of Birth

E-mail (required)

Telephone

home address

Reason for today's visit

Past Medical History

Primary care physician

Date of last exam (sick or well)

Physician’s Address

Office number

Allergies

Are you/your child allergic to penicillin or any other drugs, food, or other substances?

YesNo

If Yes, please list:

1. Name of Substance & Reaction

2. Name of Substance & Reaction

3. Name of Substance & Reaction

4. Name of Substance & Reaction

5. Name of Substance & Reaction

Medications (prescription and other vitamins/supplements):

1. Name, Dose and How many times a day

2. Name, Dose and How many times a day

3. Name, Dose and How many times a day

4. Name, Dose and How many times a day

5. Name, Dose and How many times a day

Have you/your child ever been hospitalized?
YesNo

If yes, when, where and what for?

Are you/your child being treated or have you/your child ever been treated for any of the following conditions?

Sinus problemsSeasonal allergiesEye problemsEar problemsHeart diseaseMurmurHigh cholesterolHigh blood pressureCOPDAsthmaother lung problemsHeartburn (reflux)Ulcersrectal bleedingHepatitisKidney problemsBladder problemsAny CancerDiabetesThyroid problemsStrokeAnemia or bloodSeizuresArthritisHeadachesMigrainesNeurologic problemsNeck painSkin problemsDepressionAnxietyBack painPsychiatric care

Please describe any current or past medical and dental treatment not listed above

Please list any past surgeries (including dental work) and the date(s) you/your child had them

Please list any sports and/or instruments you/your child has ever played (and the level)

Please list any injuries, accidents or traumas you/your child has ever had

Your/Your child’s Birth History:

Full-termPrematureLateC-sectionForceps/vacuumVaginal delivery

Any complications during the parent’s pregnancy, delivery or post-partum (back pains, infections, etc)?

Social and Preventive History

Have you/your child ever used smoke/chew tobacco products, alcohol or marijuana

YesNo

If yes, explain which, how much and current use?

Water intake per day in ounces:

Number of Sodas per week

DietRegular

Dietary restrictions/preference:

Describe your/your child’s sports, instruments, activities, exercise routine, or level of activity:

Immunizations

Did you/your child receive all routine childhood vaccinations?

YesNo

If no, which shots were missed and why?

Describe any difficulties you had or your child is having in school (ie. academic, social, emotional, physical, etc.)

Gyn history:

Number of pregnancies?

Full term:

Pre-term:

Abortions/miscarriage

Symptoms of menopause?

Family History
Living Age (or age at death) List serious illnesses

Mother Living?

YesNo

If no, age/cause at death

Father Living?

YesNo

If no, age/cause at death

How many siblings do you have?

Brothers

Ages

Sisters

Ages

Are your siblings living?

YesNo

If no, age at death

Has any member of your/your child’s family had any of the following illnesses:
(List illness and which family member)

Anemia or Blood disease

Cancer

Diabetes

Heart disease

High blood pressure

Mental Illness / Depression

Stroke

Musculoskeletal disorders (osteoarthritis, rheumatoid arthritis…)

Other serious illness

REVIEW OF SYSTEMS

Please mark any of the following symptoms that you/your child may currently have or within the last 3 months:

Changes in appetiteFever/ChillsWeight lossWeaknessBlurred/Double visionRunny noseSinusitisNasal congestionMouth breathingProblems with swallowingSore throatEar painShortness of breathCoughWheezingChest painPalpitationsEdema/swellingAbdominal painNauseaBloating/belchingFlatulenceVomitingDiarrheaConstipationHeartburnBurning w/urinationFrequent urinationUrgencyLoss of bladder controlWeaknessNumbnessProblems with speechMemory problemsHeadachesMigrainesVertigoDizzinessNeck painShoulder painBack painHip painKnee painAnkle/foot painElbow painWrist/hand painSkin rashBehavior problems

By submitting, you hereby certify that to the best of my knowledge all the information you have furnished on this form is complete, true and accurate.