Marne O’Shae, MD
Michele Summers, FNP & Emily Crouse, FNP
402 North Cayuga St-Ithaca-NY-14850
607-273-5551
New Patient Record
Today’s Date: _________ Patient’s Full Name: _____________________________ DOB: _________
Mother’s Name: ___________________________________ Phone Number: ____________________
Father’s Name: ____________________________________ Phone Number: __________________
1. Has your child ever had an allergy to any medication? _______ Which one? __________________________
2. Has your child ever had chickenpox (varicella)? _______________
3. Has your child ever been hospitalized? _________ For what? ______________________________________
___________________________________________________________________________________________
4. Has your child ever needed emergency treatment? ________ For what? _____________________________
___________________________________________________________________________________________
5. Has your child ever had surgery? ________ For what? ____________________________________________
___________________________________________________________________________________________
6. Does your child have any non-drug allergies/food allergies? ________________________________________
7. Does your child have any ongoing medical problems? _____________________________________________
8. Is your child in good health? _________________________________________________________________
____________________________________________________________________________________________
9. Does your child have a special diet or vegetarian? ________________________________________________
10. Has your child ever lived/spent time in an older building that has not been renovated since 1960? _________
____________________________________________________________________________________________
11. Is there a gun kept in the place where your child lives? ______ Locked up/ammo separate? ______________
Patient Health History
Has your child ever had or now have…
General History
Does child:
Yes
Eye/Vision problem
Ear/Hearing problem
Dental problems
Speech problems
Fainting Spells
Urine/Kidney Infections
Wheezing or Asthma
Heart condition/Heart murmur
Anemia/Blood problems
Bedwetting
Seizures/Convulsions
Recurrent skin rash/Eczema
Stomach or Bowel problems
Recurrent sore throat
Joint pain/swelling
Fractures/Bone problems
Rheumatic Fever
Tuberculosis
Positive TB Test
Hepatitis
No
Yes
No
Yes
No
Have immunizations up to date
Take Medicine regularly
See dentist regularly
Behavior Problems
Has your child ever had or now have…
Frequent Headaches
Trouble getting along with others
Restlessness/Fidgety
Nervousness or Fearful
Persistently Sad or Depressed
Drug/Tobacco/Alcohol use
Sexual Activity or Molestation
Trouble in School
Aggressive Behavior
Eating problems/Eating too much/little
Any other information you would like us to know about your
child?
Marne O’Shae, MD
Michele Summers, FNP & Emily Crouse, FNP
402 North Cayuga St-Ithaca-NY-14850
607-273-5551
Family History Questionnaire
Note: Only one copy of this page needs to be filled out per family. We will place a copy in each chart.
Today’s Date: ____________
Person Filling Out This Form: ___________________________ Phone number: ____________
Relationship to Child: ____________
List each Sibling’s Name and Birthdate:
Name: _____________________________________________ DOB: _______________
Name: _____________________________________________ DOB: _______________
Name: _____________________________________________ DOB: _______________
Name: _____________________________________________ DOB: _______________
Name: _____________________________________________ DOB: _______________
Please check the boxes where child’s blood relatives have any of these problems:
Father Mother Brother
Sister
Father’s
Side
Allergies (Asthma, Eczema, Hay Fever)
Birth Defects (Cleft Lip, Club Foot, Hip Dysplasia)
Blood Disorders (Bleeding, Sickle Cell, Anemia)
Bone/Joint Disorders (Arthritis, Gout)
Cancer (Leukemia, Breast Cancer, Tumors)
Cholesterol Problems
Diabetes
Eye Problems (Blindness, Lazy Eye, Crossing Eyes)
Ear Problems (Dearness/Hearing Aids)
Gastrointestinal Disorders (Ulcer, Crohn’s, Celiac)
Genetic Disorders (Down Syndrome, Cystic Fibrosis)
Heart Disease (Heart Attacks, High Blood Pressure)
Kidney Disease (Absent Kidneys, Cystic Kidneys)
Lung Disorders (Asthma, Tuberculosis)
Muscle Disorders (Multiple Sclerosis, Stiffness)
Nervous Disorders (Migraines, Seizures, Epilepsy)
Psychiatric Disorders (Depression, Suicide, Schizophrenia)
Thyroid Problems
Venereal Diseases (Syphilis, Gonorrhea, HIV, Herpes)
Alcoholism, Drug Dependency
Regular Smoker
Other:
Mother’s
Side
The following information is of value in the complete examination of your child.
ANSWERING IS OPTIONAL AND OF COURSE CONFIDENTIAL!
YES
Are there any problems at home we should be aware of?
Have parents been divorced or separated?
Children reside with?
NO