Portal Home

Patient History Form Ages 12+ Years

PLEASE NOTE:
This form must be filled out completely. If a question does not apply, please mark "No" and/or fill in the field with "N/A". All questions are important for our office to better serve our patients.

Email Address:


Confirm Email:


Phone Number:


Child's Name:


Form Filled Out By:


Date Filled Out:


BIRTH AND MEDICAL HISTORY:

Any problems during pregnancy, delivery, or after delivery?     Yes  No
If Yes, Please Describe:


Any problems as a baby?     Yes  No
If Yes, Please Describe:


Do any foods seem to bother you child?     Yes  No
If Yes, Please List Kinds:


Have you ever had surgery of any kind?     Yes  No
If Yes, Please List Kinds:


Have you had any chronic illnesses?     Yes  No
If Yes, Please List Kinds:


Have you had to stay in the hospital?     Yes  No
If Yes, Please List Nature:


Have you had any serious accidents?     Yes  No
If Yes, Please List Kinds:


Do you take any medications?     Yes  No
If Yes, Please List:


Do you have any allergies?     Yes  No
If Yes, Please List:


Do you have any developmental problems?     Yes  No
If Yes, Please List:


What grade are you in?     

What are your plans after school?     Yes  No
If Yes, Please Describe:


PERSONAL, SOCIAL, AND FAMILY HISTORY:

Does anyone in family have problems with their bowel, colon, stomache, liver, gall bladder, esophagus, or pancreas?  Yes  No
If Yes, Please List Who and What:


Does anyone in your family have nervous system problems or migraine headaches?     Yes  No
If Yes, Please List Who and What:


Are there any allergies in your family?     Yes  No
If Yes, Please List Who and What:


Does anyone in the family have any other serious illnesses?     Yes  No
If Yes, Please List Who and What:


Mother's Name:


Mother's Occupation:


Father's Name:


Father's Occupation:


Step-Parent Name (If Applicable):


Step-Parent Occupation (If Applicable):


Step-Parent Name (If Applicable):


Step-Parent Occupation (If Applicable):


Child's Brothers and Sisters:


How many people live in child's home?
Adults:    Children:  

Who do you live with more than half-time (Example: Mother, Father, Guardian, Etc.)?

Please list places you have traveled outside of the U.S. in the past year (dates and locations):


Please list all animals and pets you are around (home, school, or otherwise):


Do you drink well water (at any location)?
Yes  No

Have you been exposed to any toxins (list even if unsure)?
Yes  No
If yes, please describe:   

What activities and sports do you participate in?     

Do you have a job?     Yes  No
If Yes, Please Describe:


Are you sexually active?     Yes  No
If Yes, Please Describe and List Birth Control Used:


Do you smoke or use tobacco products?     Yes  No
If Yes, Please Describe Usage:


Do you drink alcohol?     Yes  No
If Yes, Please List What and When:


REVIEW OF SYSTEMS:
PLEASE MARK IF YOUR CHILD HAS EXPERIENCED ANY OF THE SYMPTOMS/CONDITIONS BELOW
EACH SECTION REQUIRES AT LEAST ONE BOX CHECKED:

General:
Poor or Decreased Appetite      Excessive or Increased Appetite
Excessive or Increased Thirst      Overweight or Weight Gain
Underweight or Weight Loss      Too Tall      Too Short
Difficulty Sleeping      Excessive Sleeping
No Energy      Fevers      Chills      None

Skin:
Skin Rash (of any kind)      Unexplained Lumps
Seems to Easily Bruise or Bleed      Unexplained Itching      Jaundice
None

Eyes:
Eye Pain      Blurred Vision      Wears Glasses
Recent/Sudden Change in Vision
None

Ears-Nose-Throat:
Earaches      Decreased Hearing      Frequent Nosebleeds
Bad Teeth      Trouble Swallowing      Sore Throat
Canker Sores      Runny Nose
None

Respiratory:
Hoarseness      Cough      Wheezing
Difficulty Breathing      Shortness of Breath Attacks
Noisy Breathing      Snoring
None

Cardiovascular:
Chest Pain      Heart Murmur
High Blood Pressure      Heart Trouble
None

Gastrointestinal:
Abdominal Pain      Nauseanbsp;     Vomitting
Indigestion      Heart Burn      Bloating
Diarhhrea      Constipation      Blood in Stools
Stool in Underwear (Soils)
None

Urinary:
Painful Urination      Increased Frequency of Urination
Daytime Wetting      Bed Wetting
None

Skeletal:
Back Pain      Limp      Swollen Joints
Swollen Arms or Legs      Joint Pain
None

NeuroMuscular:
Headache      Migraines      Weakness
Paralysis      Numbness      Loss of Balance
Dizziness      Unexplained Movements or Jerks
Convulsions      Staring Spells      Fainting
None

Behavioral:
Recent Changes in Family      Increase in Stress
Child is a Worrier      Child is a Perfectionist
Depressed      Hyper-Activity      Breath Holding
Confusion
None

FEMALES: Have you started your menstrual periods?     Yes  No
If Yes, Please Note When it Began (Month/Year):     
Check All That Apply:
Painful Periods      Excessive Bleeding      Other Problems
None


Thank you for taking the time to fill out this form, we do appreciate your efforts. Your health is important to us, your answers will help us serve your needs better.