Patient Resources Online Forms
Patient Resources

Pediatric - Medical History Form



General Information
Date of Visit*
 
OC Location*
First Name*
 
Last Name*
Date of Birth*
 
Age*
Who is your Primary Care provider?
 
Gender
Male Female
Height
 
Weight
Pharmacy and Phone #
Please describe reason for today's visit:
If visit is related to an injury, how did injury occur?
None Fall Sports/Recreation Motor Vehicle accident
Other:
Medical History
None OR Check Past or Current Problem
(Enter Other if problem not listed)

ADD
None Past Current
ADHD
None Past Current
Alcohol Abuse
None Past Current
Anemia
None Past Current
Arthritis
None Past Current
Asthma
None Past Current
Blood Disorders
None Past Current
Cancer
None Past Current
Cerebral Palsy
None Past Current
Club Foot
None Past Current
Cystic Fibrosis
None Past Current
Delay In Development
None Past Current
Depression
None Past Current
Diabetes
None Past Current
Difficulty Walking
None Past Current
Drug Abuse
None Past Current
Dysplasia of Hip
None Past Current
Heart disease
None Past Current
High Blood Pressure
None Past Current
High Cholesterol
None Past Current
HIV / AIDS
None Past Current
Kidney Disease
None Past Current
Liver Disease
None Past Current
MRSA
None Past Current
Pregnancy
None Past Current
Scoliosis
None Past Current
Seizures
None Past Current
Sickle Cell Disease
None Past Current
Spina Bifida
None Past Current
Thyroid Disease
None Past Current
Sickle Cell Trait
None Past Current
Other
List Drug/Food Allergies and Reaction:
None
List Current Medications:
None
List Any Past Surgeries and Date:
None
Family & Social History
None Adopted Unknown OR indicate if any of the patient's blood relatives have had any of the following conditions, check all that apply.
Anemia
Arthritis
Asthma
Autism
Blood Disorders
Cancer, type:
Cerebral Palsy
Club Foot
Delay in Development
Diabetes
Difficulty Walking
Dysplasia of Hip
Gastrointestinal Disease
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Disease
Liver Disease
Neurological Disorder
Sickle Cell Disease
Sickle Cell Trait
Scoliosis
Seizures
Spina Bifida
Thyroid Disease
Other:
Lives at home with:
 
Grade in school:
Tobacco Use
Yes No
Alcohol Use
Yes No
Current or Past Drug Use:
Yes No
General Health
In the past 3 months has the patient had:
Fever Rash Infection Required Medication
Has the patient had problems with the same orthopedic problem they are being seen for today?
Yes No
If yes, please explain:
Does the patient have a current problem in any of the following?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Has the patient had any of the following tests/procedures related to this problem?
If yes, please check and provide date
X-Ray
 
Myelogram
Lab work
 
Physical Therapy
CAT Scan
 
Bone Scan
Pain Management
 
MRI
EMG/NCV
Additional Information
IF YOUR CHILD IS BEING SEEN FOR AN INJURY OR TRAUMA (BROKEN BONE, SPRAIN, SPORTS INJURY, ETC) IT IS NOT NECESSARY TO COMPLETE THE FOLLOWING QUESTIONS. Proceed to end of page and submit form.
Birth and Development history
Weeks gestation
Birth weight
Type of delivery
Vaginal Cesarean Breech
Complications with pregnancy or delivery
None, OR
This is my
1st 2nd 3rd 4th 5th, Other (born child):
Age child sat independently
months
Age child walked independently
months
Does your child have any physical/mental disabilities?
No Yes
If Yes, please describe:
Special Needs Children
Does your child wear orthotics?
No Yes

If yes, please specify:
AFO SMO DAFO HKAFO Shoe Lift
Other:
Does your child attend any type of therapy?
No Yes

If yes, please specify:
PT OT ST
Other:
Does your child walk independently?
No Yes

If no, please specify type of assistance required:
Wheelchair Stander Reverse Walker
Lofstrand Crutches
Other:
Does your child communicate verbally?
No Yes

If no, please specify method of communication:
Scoliosis Patients
Who noticed the curve?
Parent Patient Physician School Representative
Other:
Is there a family history of scoliosis?
No Yes

If yes, please indicate relative:
If female, please indicate the date of first menstrual cycle
Does the patient have back pain?
No Yes