Page 1 of 6
Pediatric Patient Information (0-11 years old)PG-2003 rev. 04/17
PATIENT INFORMATION
Name: ___________________________________________________________________________________ SSN: _________________________________________ Last First MI
Sex: M F DOB: __________________________ Preferred Name: ____________________________________________________________________
Address: __________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________ City State ZipMailing address: Check if same as above____________________________________________________________________________________________________________________________________________ Address
____________________________________________________________________________________________________________________________________________ City State Zip
Home Phone: ______________________________________________________ Cell: ________________________________________________________________
Would you prefer to speak to your healthcare provider through a translator? Yes No
Preferred Language: English Other (please specify): __________________________ Written Language: _________________________Religion: _______________________________________________ Declined Birthplace: ___________________________________________________Ethnicity: Do you consider yourself to be Hispanic or Latino? Yes No DeclinedRace: American Indian or Alaska Native Native Hawaiian or other Pacific Islander White Black or African American Asian DeclinedPHARMACY Address/Cross Streets Phone Number PreferredLocal: __________________________________ ______________________________________________________ __________________________ Alternative: ____________________________ ______________________________________________________ __________________________ Mail Order: ____________________________ ______________________________________________________ __________________________ CARE TEAM
Primary Care Provider: ___________________________________________________________________ Phone Number: ___________________________
Specialist Name: _______________________________ Specialty: _______________________________ Phone Number: ___________________________
Specialist Name: _______________________________ Specialty: _______________________________ Phone Number: ___________________________
Complete New Patient Paperwork Online! Visit epic.mycenturahealth.org to complete your Health History Questionnaire and update your information.
EMERGENCY CONTACT
Name: ______________________________________________________________ Relation to patient: _______________________________________________ Last FirstAddress: _______________________________________________________________________________________________________________________________
Phone: ______________________________________________________
Name: ______________________________________________________________ Relation to patient: _______________________________________________ Last FirstAddress: __________________________________________________________________________________________________________________________________
Phone: ______________________________________________________
Yes No Legal Guardian:
Yes No Legal Guardian:
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Pediatric Patient Information (0-11 years old)PG-2003 rev. 03/17
Advance DirectiveDo you have a Living Will / DNR? Yes NoDo you have a Durable Power of Attorney? Yes NoIf yes: ____________________________________________________________________________________________________________________________________ Please Print Name Phone NumberWould you like information regarding Advance Directive? Yes No
SUBSCRIBER INFORMATIONName: __________________________________________________________________________________________ DOB: ___________________________________ Last First mm/dd/yyAddress: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ City State ZipPhone: _____________________________________________ SSN: _______________________________________________ Relation to patient: ________________________________________________________________Employer: _______________________________________________
MEDICATIONS NonePlease list any medications you are taking (including aspirin, vitamins, supplements or any other over the counter medication). Name of Medication Dose How often do you take Reason for taking medication
Chief Complaint (Reason for Visit): _____________________________________________________________________________________________________________________
ALLERGIES No Known Drug Allergies Medication: ___________________________________________________ Reaction: ______________________________________________________________ Medication: ___________________________________________________ Reaction: ______________________________________________________________
Other (latex, adhesive, food, environment): ________________________________________________________________________
Medication: ___________________________________________________ Reaction: ______________________________________________________________Other (latex, adhesive, food, environment): ________________________________________________________________________
Full Time/Part Time: _______________________________________________
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Pediatric Patient Information (0-11 years old)PG-2003 rev. 03/17
PERSONAL MEDICAL HISTORYPlease check all diagnoses that apply to you and add notes as needed.
AIDS Yes NoAnemia, Type: _________________________________________ Yes NoAsthma Yes NoBleeding / Clotting disorder Yes NoChronic Pain Yes NoCongenitial Yes NoConstipation Yes NoDiabetes, Type: _______________________________________ Yes NoDisabilities: ____________________________________________ Yes NoEar Infection, recurrent Yes NoEnvironmental/Food Allergies: _______________________ Yes NoGERD (Reflux) Yes NoHead Injury/Concussion Yes NoHearing Deficit Yes NoHIV Yes NoLong-Term Steroid Use Yes No
Oxygen Use Yes NoPneumonia, recurrent Yes NoScoliosis Yes NoSeasonal Allergies: ___________________________________ Yes NoSeizures, Type: ________________________________________ Yes NoSnoring Yes NoThroat infection, recurrent Yes NoThyroid Problems Yes NoTuberculosis exposure Yes NoUTI (Bladder infections) Yes NoOther Conditions: _____________________________________ Yes No_________________________________________________________ _________________________________________________________ _________________________________________________________ Date of last dental exam: ____________________________ Date of last vision exam: _____________________________
BIRTH HISTORY Hospital of Delivery? ________________________________________________________________________________________________________________
(Name) (City, State/Zip)Birth Weight: __________________________ Weeks Pregnant (Gestational age): _______________________________________________________Complications with Pregnancy/Delivery/Hospital Stay? Yes NoExplain if ✓ Yes: ________________________________________________________________________________________________________________________Hearing Screen passed in hospital? Yes No Don't Know
PATIENT INFORMATIONName: ___________________________________________________________________________________ DOB: _________________________________________ Last First MI
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Pediatric Patient Information (0-11 years old)PG-2003 rev. 03/17
Have you ever had a reaction to general anesthesia? Yes NoAdditional Personal Medical History________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Tobacco Use: Second hand smoke exposure No second hand smoke exposure
SOCIAL HISTORY (Complete for current age)Diet: (0-24 months)Breastfed: Yes NoVitamin Supplement: Yes NoFormula: Yes No
Diet: (24 months-11 years) Breastfed Age Appropriate Vegetarian High Fat/Calorie Intake Other
Exercise/Activity Level: Sedentary Strength/Wt. Training Active Twenty minutes/day exercise Exercise three times weekly Aerobic/Cardiac
SURGICAL HISTORYPlease list surgeries/procedures and add notes as needed.
Year Surgery/Procedure Hospital/Location Complications/Additional Comments
Name: _______________________________________________________________________________________________________ DOB: ______________________________________ Last First MI mm/dd/yyyy
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Pediatric Patient Information (0-11 years old)PG-2003 rev. 03/17
PLEASE USE THIS SPACE FOR ANY ADDITIONAL INFORMATION
___________________________________________________________________________________________________________________________________________
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With whom do you live? Mom Dad Both Parents Sibling Other: ____________________________________________
Education: Day Care (name): ________________________________________________ Grade School: (current grade) __________________
In the last 30 days, have you traveled to any foreign countries? Yes No List: _______________________________
Do you: Use seatbelts Use a helmet Have guns in home Have smoke detector in home Car Seat/Booster
Concerns about learning or development skills (specify): ____________________________________________________________________________
Concerns about behavior or social skills (specify): ___________________________________________________________________________________
How many hours of screen time/day: _____________________
IMMUNIZATIONS All Immunizations current Unknown
Please provide any known dates or full immunization record(s).
Name: _______________________________________________________________________________________________________ DOB: ______________________________________ Last First MI mm/dd/yyyy
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Pediatric Patient Information (0-11 years old)PG-2003 rev. 03/17
FAMILY HISTORYWhat illnesses/conditions/diagnoses are in your family? Indicate the age of diagnosis in the boxes below, if known.
Name: _______________________________________________________________________________________________________ DOB: ______________________________________ Last First MI mm/dd/yyyy
Alcohol a
buse
Asthma
Blood clots
Breast
cance
r
Colon cance
r
Prostate
cance
r
Other ca
ncer(s
)
Demen
tia
Diabete
s
Heart
diseas
e
High blood pressu
re
High choles
terol
Kidney dise
ase
Liver d
iseas
e
Lung diseas
e
Mental
Illnes
s
Stroke
Thyroid co
ndition(s)
Other:___
______
Ovaria
n Can
cer
Other:___
_____
Other:___
______
No Known Problems
Mother
Father
Sister
Brother
Son
Daughter
Other:_______
Other:_______
Other:_______
Relationship Name Status
Maternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather
Page 1 of 1
Review of SystemsPG-2001 rev. 08/16
Patient Label
Please check any symptoms you've experienced over the LAST ONE TO TWO WEEKS:
_________________________________________________________________________________ _________________________________________________________________________ ____________________________________ Patient or Guardian Name (please print) Patient or Guardian Signature Date
General/ Constitution Activity Change Appetite Change Chills Diaphoresis (Sweating) Fatigue Fever Irritability Unexpected Weight Change
Ear, Nose & Throat Congestion Dental Problems Drooling Ear Discharge Ear Pain Facial Swelling Hearing Loss Mouth Sores Nosebleeds Postnasal Drip Rhinorrhea (Runny Nose) Sinus Pressure Sneezing Sore Throat Tinnitus (Ringing in the Ears) Trouble Swallowing Voice Change
Eyes Eye Discharge Eye Itching Eye Pain Eye Redness Photophobia (Sensitivity to Light) Visual Disturbance (Blurred Vision)
Respiratory Apnea Chest Tightness Choking Cough Shortness of Breath Stridor (Airway Obstruction) Wheezing
Cardiovascular Chest Pain Leg Swelling Palpitations (Irregular Heart Beat)
Gastrointestinal Abdominal Distention (Bloating) Abdominal Pain Anal Bleeding Blood in Stool Constipation Diarrhea Nausea Rectal Pain Vomiting
Endocrine Cold Intolerance Heat Intolerance Polydipsia (Abnormal Thirst) Polyphagia (Abnormal Hunger) Polyuria (Abnormal Urination)
Genitourinary Difficulty Urinating Dysuria (Painful Urination) Enuresis (Involuntary Urination) Flank Pain (Low Back Pain) Frequency Change (Urinary) Genital Sores Hematuria (Blood in Urine) Menstrual Problems Pelvic Pain Penile Discharge Penile Pain Penile Swelling Scrotal Swelling Testicular Pain Urinary Urgency Changes in Urine Stream Vaginal Bleeding Vaginal Discharge Vaginal Pain
Musculoskeletal Arthralgias (Joint Pain) Back Pain Gait Problems Joint Swelling Myalgias (Muscle Pain) Neck Pain Neck Stiffness
Skin Color Change Pallor (Paleness) Rash Wounds
Allergy/Immunologic Environmental Allergies Food Allergies Immunocompromised
Neurologic Dizziness Facial Asymmetry Headache(s) Light Headedness Numbness Seizures Speech Difficulty Syncope (Loss of Consciousness) Tremors Weakness
Hematologic Adenopathy (Swollen Glands) Bruising Tendency Bleeding Tendency
Behavioral Agitation Behavioral Problems Confusion Decreased Concentration Dysphoric Mood (Mood Changes) Hallucinations Hyperactive Nervousness Anxiety Self Injury Sleep Disturbance Suicidal Thoughts
Any other symptoms: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________