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PEDIATRIC GASTROENTEROLGY HEPATOLOGY & NUTRITION CLINIC

New Patient History Form

(Please fill out this form and bring it with you to your appointment)

CHILD’S NAME:______________________PRIMARY DOCTOR: ________________

PHARMACY you want to use: Name:_______________________________________

Street: ______________________________________City: ____________________________

Why are you bringing your child to the GI clinic?________________________

When did the problem start? __________________________________________________

How often does the problem occur?__________________________________________

FAMILY HISTORY: (Circle ALL that apply)

Does ANYONE in the family have the following illnesses on mother or father’s side,

Including parents, siblings, first cousins, grandparents, aunts or uncles, etc.?

SEIZURES, MIGRAINES, HEART ATTACKS/DISEASE, STROKE, ASTHMA, ECZEMA, ALLERGIES, HIGHBLOOD PRESSURE, THYROID DISORDER, DIABETES, ULCERS, GALL STONES, ULCERATIVE COLITIS, CROHN’S DISEASE, MISCARRIAGES, GASTROINTESTINALSURGERY, POOR GROWTH, POOR WEIGHT GAIN, SUDDEN INFANT DEATH SYNDROME, APNEA, DIARRHEA, CELIAC DISEASE, LIVER PROBLEMS, KIDNEY PROBLEMS, BLEEDING PROBLEMS, LACTOSE INTOLERANCE, CONSTIPATION, HEARTBURN (REFLUX), COLON CANCER, ESOPHAGEAL CANCER, AND OTHER CANCERS (list types), OTHER ILLNESSES?

_____________________________________________________________________________

AGES & SEX OF BROTHERS AND SISTERS:

_____________________________________________________________________________

MOTHER’S PAST MEDICAL HISTORY WITH THIS CHILD:

Any problems during pregnancy with this child: (Bleeding, infection, premature labor, medications taken during pregnancy, other): ______________________________________________________________________________

Any problems during delivery? (Premature, infection, Cesarean, resuscitation, other)

_______________________________________________________________________________

Any problems in the nursery? (Jaundice, infection, not passing stool, other)

______________________________________________________________________________

Patients’ birth weight: ______________

PATIENT’S PAST HOSPITALIZATIONS & SURGERIES:

Reason Date Name & Location of Hospital

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

PATIENT’S SIGNIFICANT ILLNESSES: (Circle & explain ALL that apply)

Heart problems, Lung problems, Bladder/kidney infection, Seizures, Cancer, Blood pressure problems, Bleeding problems, Asthma, Seasonal allergies, Mental illness, ADD, ADHD, Others

(list below)

If patient is female: Date patient’s periods first started? _______________________

Are they regular (circle)? Yes / No

DEVELOPMENTAL HISTORY OF CHILD: Normal ____________ Delayed __________

TRANSFUSION HISTORY: Has your child received any blood products? Yes/No

DIET HISTORY: Does your child eat the following?

Sugarless gum or sugarless candy (circle)? Yes/ No/ Unknown

Fruit juice, non-diet soda, sports drinks. Does child consume greater than 8oz a day

of those types of drinks frequently (circle)? Yes/ No/ Unknown

Dairy products (circle)? Yes/ No/ Unknown ;Ounces per day consumed____________

Fruit or vegetables: 5 or more per day (circle)? Yes/ No/ Unknown

Fluid (not including milk): Greater than 1 quart per day (circle)? Yes/ No/ Unknown

Type of drinking water (circle)? : Well /Bottled /City

Ground fresh water exposure; i.e. exposure to lakes, rivers, streams, etc. (circle)? Yes / No

Is your child is on a special diet (circle)? Yes/No Low cholesterol, Gluten free,

Lactose free, Other________________________________________________________

DIET: Please indicate the formula your child is on, how many ounces your child takes at a time, and how many times per day the formula is taken. Also, indicate the amount of water or juice your child takes per day. Please indicate whether your child can be orally fed or takes their feedings by gastrostomy tube. (Example: 8oz Pediasure 4 times a day. 1oz water 4 times a day).

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

SOCIAL HISTORY:

Child’s grade in school: _________ Performance (circle): good /average/poor

Who lives with child? ________________________________________________________

Does child have friends (circle)? Yes/ No/ Unknown

Stressful events at school (circle)? Yes/ No/ Unknown (explain)

Stressful events at home (circle)? Yes/ No/ Unknown (explain)

Smoking or chewing tobacco by child (circle)? Yes/ No/ Unknown

Drugs or alcohol use by child (circle)? Yes/ No/ Unknown

Tattoos or piercing of child (circle)? Yes/ No/ Unknown

Is child sexually active (Circle)? Yes/ No/ Unknown

Mother’s Occupation_____________________Father’s Occupation________________________

Marital status of child’s parents (circle)? Married, Separated, Divorced, Single, Widowed

Child’s Animal/Pet exposure (Dogs, cats, birds, etc.)? ________________________________

Travel outside the state (circle)? Yes /No Date: ____________ Location: _______________

MEDICATIONS: Please list all the medications your child is on, the dosage, and the number of times per day your child takes the medication. (If there are a number of medications, you may copy the medication list and staple list to this page). Please remember to write down the milligrams of the tablet or capsule your child is on or milligram/milliliter or the liquid of the medication your child is on. (Don’t forget vitamins, herbal medications, inhaled medications, and medicated ointments)

__________________________________________ ________________________________

__________________________________________ ________________________________

PLEASE CHECK ANY OF THE FOLLOWING SYMPTOMS YOUR CHILD HAS OR HAS HAD RECENTLY

|GENERAL |YES |NO |HEAD |YES |NO |

|Tiredness | | |Frequent sore throat or hoarseness | | |

|Fever | | |Frequent cavities | | |

|Decreased activity | | |Visual or hearing problems | | |

|Decreased appetite | | |Frequent ear or sinus infections | | |

|Missing school | | |Mouth sores | | |

|Poor weight gain/weight loss | | |Swallowing problems | | |

|Excessive weight gain | | |Retching/gagging/choking | | |

|Poor sleeping | | |Pain on swallowing | | |

|Irritability/Increased crying | | |Food getting stuck after swallowing | | |

|CHEST |YES |NO |NERVOUS SYSTEM |YES |NO |

|Stopped breathing | | |Seizures | | |

|Turned blue | | |Depression | | |

|Shortness of breath | | |Change in personality | | |

|Cough | | |Anxious | | |

|Wheezing | | |Headache | | |

|Pneumonia | | |Difficulty with school | | |

|Bronchitis | | |Dizziness | | |

|Chest pain | | | | | |

|GASTROINTESTINAL |YES |NO |KIDNEYS/BLADDER/REPRODUCTION |YES |NO |

|Abdominal bloating | | |Pain on urination | | |

|Abdominal pain | | |Frequent urination | | |

|Nausea | | |Blood in urine/Dark urine | | |

|Vomiting | | |Irregular or painful periods | | |

|Diarrhea | | |Discharge from penis or vagina | | |

|Constipation | | |BONES/MUSCLES/JOINTS | | |

|Vomiting blood | | |Joint pain | | |

|Blood in the stool | | |Joint swelling | | |

|Black stool | | |Back pain | | |

|Pale stool | | |SKIN | | |

|Excessive burping | | |Rash | | |

|Excessive gas | | |Bruises or bleeds easily | | |

|Regurgitation | | |Eczema | | |

Please list other physicians following your child so that we can send them a letter and update them on your child’s progress. Please indicate whether your child is being followed by other agencies such as, CCS, CVRC, Home Health Nursing, etc.

________________________________________________________________

IMMUNIZATIONS UP TO DATE: Yes/No

ALLERGIES TO MEDICATIONS: (Please list medications and reactions):

_________________________________________________________________

Signature: ______________Relationship to child: __________Date: _________ Revised 12/09

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