Pediatric Otolaryngology New Patient Questionnaire PLEASE

PATIENT LABEL HERE
Pediatric Otolaryngology New Patient Questionnaire
Department of Otolaryngology Head & Neck Surgery
601 N. Caroline Street, Baltimore, MD 21287, Fax: (410) 955-0035
Patient’s Name:______________________________________________ Date of Birth: _____________
Address:____________________________________City:___________________State/Zip:___________
Home Phone: (
) ____________________ Cell: (
) ____________________Other: _____________
Referring Physician: _______________________Primary Care Physician:_________________________
Parent or Guardian name:________________________________________________________________
Reason for Today’s Visit:________________________________________________________________
Birth History
Problems with Pregnancy?
If yes, please explain:
Problems with Delivery?
If yes, please explain:
Type of Delivery:
Vaginal
Birth Weight: _______lbs ________oz
NO YES
Apgar scores:_______________________
NO YES
Cesarean
Full Term?: NO YES, If no, how early? ______
Was newborn in the NICU?
NO YES
If yes, how long?_________________________
Why?__________________________________
_______________________________________
_______________________________________
Did newborn pass hearing screen? NO YES
Please list any MEDICATIONS your child is currently taking:
MEDICATION NAME
DOSAGE
WHEN TAKEN
1.
2.
3.
4.
5.
Are there any medication allergies? NO YES If yes, please list:
Medical History
Does your child have any other conditions/illnesses/diagnoses?
If yes, please tell us what:
NO YES
Has your child ever been in a hospital overnight?
If yes, please provide dates and reason:
NO YES
Has your child ever had surgery (an operation)?
If yes, please tell us what kind of surgery and when:
NO YES
PLEASE COMPLETE THE OTHER SIDE OF FORM
How Long?
Are your child’s immunizations up to date?
NO YES
Has your child experienced normal growth and development?
If no, please describe:
NO YES
Please check if your child is experiencing any of the following:
___Eye or vision problems
___Thyroid problems
___Ear infections/fluid
___lymph node swelling
___Ear pain or drainage
___Mass in neck
___Hearing loss
___Asthma
___Runny/congested nose
___Cough
___Sinus infections
___Pneumonia
___Seasonal or food allergies
___Heart problems
___Nosebleeds
___Weight loss or gain
___Throat infections
___Stomach pain
___Snoring
___Diarrhea
___Dental problems
___Difficulty swallowing
___Voice changes
___Constipation
___Urine/kidney problems
___Bedwetting
___Joint pain or swelling
___Muscle weakness
___Anemia/blood problems
___Seizures
___Headaches
___Rashes or birth marks
___Speech delay
___Problems with sleep
___Behavior problems
___Psychiatric problems
Please describe any checked items or other problems not listed:________________________________
____________________________________________________________________________________
Family History
Is there any family history of:
If yes, please describe who and what:
Excessive bleeding?
NO YES
______________________________
Problems with anesthesia?
NO YES
______________________________
Asthma?
NO YES
______________________________
Allergies?
NO YES
______________________________
Hearing loss?
NO YES
______________________________
Genetic or inherited disease?
NO YES
______________________________
Other ?
NO YES
______________________________
Social History
Is your child in day care?
NO YES
If yes, How many children in daycare room?___
Does your child attend school?
NO YES
If yes, what grade?______________
Who lives at home?_____________________________________________________________________
Are there other siblings?
NO YES
Are there smokers at home?
NO YES
Are there pets at home?
NO YES
If yes, what age?:_________________________
If yes, what kind?_________________________
Any other concerns or problems you would like us to know about?
Provider/Physician Signature:_______________________________________Date:_________________
Updated 7/09