Patient Information

Patient Name
Today's Date			Date of Birth
Referring Physician			Primary Care Physician

1. Reason for your visit today

2. Please indicate if you (the patient) are currently having problems,
    signs or symptoms in any of the following areas:

No Yes Fever, weight loss, fatigue, etc. Eyes Ears, Nose, Mouth, Throat Stomach / Digestion Lungs / Breathing Heart / Circulation Muscle / Joints / Bones

No Yes Neurological Allergies Thyroid / Endocrine Psychiatric Blood / Lymph Skin Urinary / Reproductive

3. Past Medical History Present Medications Birth Weight Date of last dental checkup?   No Yes Has the patient been diagnosed with a heart murmur? Any history of being blue or cyanotic? Any hospitalizations other than for birth?      For what? Any serious injuries or illness?      What kind? Has the patient had any surgeries?      List surgeries: Has the patient been diagnosed with developmental problems? Are the patient's immunizations up to date? Does the patient have asthma? Is the patient menstruating?      Last menstrual date: 4. Allergies   No Yes Has the patient had allergic reactions? 5. FAMILY HISTORY What is the Health Status of the patient's family?    Mother:    Father:    Brothers / Sisters:   No Yes Are there any close relatives born with heart problems? Is there a history of sudden death in the family? Are there any family members with pacemakers? Is there a history of hypertrophic cardiomyopathy? Is there a history of long QT Syndrome in the family? Is there a history of heart disease, heart attack, heart failure?

FEEDING / NUTRITION (Early Life) No Yes Is your child's appetite usually good?    Is it good now? Any feeding difficulties? Any excessive sweating? Any difficulty breathing (hard/fast)? Current feedings:       Breast Milk      Frequency & times:   Formula      What type?      Amount / Feed?     GROWTH /DEVELOPMENT   No Yes Do you have any concerns about the patient's growth or development?     ACTIVITY DOES THE PATIENT... No Yes • have exercise limitations? • get short of breath with exercise? • get dizzy with exercise? • get chest pain with exercise? • pass out with exercise? • perform adequate activity for age?

6. PATIENT'S SOCIAL HISTORY

Marital Status: Single | Divorced | Married | Widow(er)

Current Employer:

Who does the patient live with? (Mom, Dad, Sisters, Brothers, Spouse, etc.):

Name of school patient attends and grade:

Does the patient smoke? No | Yes

How many packs per day? For how many years?

Does the patient drink alcohol? No | Yes

How many drinks per day / week / month?

Does the patient use illicit drugs? No | Yes

If yes, what kind?