Patient Information Form Pediatric Urology Practice John T.B. Houston, M.D. Details FLS LP NLX WST Children's Memorial Community Physician's Association, Chicago, IL AMBULATORY RECORD Dear Patient: Please take a few minutes to complete the first three pages of this form. This will help assure you of the best possible care and will be held in confidence as part of your medical record.Today's date: MM slash DD slash YYYY Medical Record #:Patient name:Date MM slash DD slash YYYY Reason for this visit:Primary Care Physician:Referred By: Primary Physician Other M.D. Self Friend Other PAST MEDICAL HISTORY Has your child ever had problems with the following (Circle One) Immunizations up to date Yes No Was your child premature? If yes, number of weeks Yes No Abnormal prenatal ultrasound Yes No Does your child have problems with any of the following: Heart disease Yes No Asthma Yes No Nervous system Yes No Autism/Autism Spectrum Yes No Coordination difficulties Yes No Constipation Yes No Developmental milestones Yes No Bleeding problems Yes No AIDS/HIV Yes No Other Medical Conditions/ Illnesses:Please list any surgical procedures your child has had and the approximate yearDate MM slash DD slash YYYY Medical Record #:Patient name:Date of birth: MM slash DD slash YYYY PCP:Please list all medications your child is taking (include non-prescription drugs)Please indicate allergies your child has to any medications and the type of reaction:Family History Mother Still alive & Healthy Yes No AgeHistory of urologic problems including bedwetting, unusual reactions to anesthesia, blood clotting problems, etc.Father Still alive & Healthy Yes No AgeHistory of urologic problems including bedwetting, unusual reactions to anesthesia, blood clotting problems, etc.Sibling Still alive & Healthy Yes No AgeHistory of urologic problems including bedwetting, unusual reactions to anesthesia, blood clotting problems, etc.Sibling Still alive & Healthy Yes No AgeHistory of urologic problems including bedwetting, unusual reactions to anesthesia, blood clotting problems, etc.Sibling Still alive & Healthy Yes No AgeHistory of urologic problems including bedwetting, unusual reactions to anesthesia, blood clotting problems, etc.Sibling Still alive & Healthy Yes No AgeHistory of urologic problems including bedwetting, unusual reactions to anesthesia, blood clotting problems, etc.Social History School Grade:Lives with parents? Mother Father Both Other OtherMother's Name:OccupationHome #-Address:Work #-Cell #-City:State:Zip:Father's Name:OccupationHome #-Address:Work #-Cell #-City:State:Zip:Primary Insurance:Secondary Insurance:Patient name:Date MM slash DD slash YYYY Medical Record #:Date of birth: MM slash DD slash YYYY PCP:Review of Systems Does your child now or has he/she had any recent problems related to the following systems? Circle Yes or NoGeneral Fever Yes No Chills Yes No Abnormal growth Yes No Abnormal development Yes No OtherSkin Rashes Yes No Continued itching Yes No Easy bruising Yes No OtherEyes Blurred vision Yes No Redness Yes No Pain Yes No OtherMuscle system Joint pain Yes No Back pain Yes No Muscle cramping Yes No OtherAllergies Hay Fever Yes No Drug Allergies Yes No Foods Yes No OtherEar Nose Throat /Mouth Ear Infections Yes No Sore Throat. Yes No Sinus problems Yes No Snoring Yes No OtherNervous System Seizures Yes No Abnormal Walking Yes No Abnormal coordination Yes No OtherGenital/Urinary Blood in urine Yes No Burning w/ urination Yes No Frequent urination Yes No Age of onset menstruation (yr) Yes No Regular Menstrual Periods Yes No OtherHormone System Excessive Thirst Yes No Tired/Sluggish Yes No Abnormal hair growth Yes No OtherLungs Wheezing Yes No Frequent cough Yes No Shortness of breath Yes No OtherStomach /Intestines Stomach pain Yes No Nausea/vomiting Yes No Constipation Yes No OtherBlood/Lymph --lands Swollen glands Yes No Blood clotting problems Yes No OtherHeart Heart Murmur Yes No High blood pressure Yes No OtherPsychiatric ADD/ADHD Yes No Depression Yes No OCD Yes No Other Δ back to top
