adolescent health history

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OKLAHOMA ORTHOPEDIC ONCOLOGY
ADOLESCENT HEALTH HISTORY QUESTIONNAIRE
NAME: ________________________________________ TODAY’S DATE: ______________________________
HEIGHT: _________ WEIGHT: _________ AGE: ______ BIRTHDATE: __________________ SEX: M
F
Student (where, what year?): _____________________________________________________________________
List current Medications: (please circle NONE if you are not taking any medications) _____________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
List any Medication Allergies: (circle NONE if you have no allergies) _________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Other Allergies: ________________________________________________________________________________
Chief Complaint
For what reason are you seeing the Doctor today? ____________________________________________________
_____________________________________________________________________________________________
Date of first symptoms: ____________ Date you first consulted a Doctor for these symptoms: _________________
Is the patient: Limping (if yes, how often, when?)____________________________________________________
Waking up at night complaining of pain (if yes, what relieves it?)____________________________
Changed their level of activity (if so, how?) _____________________________________________
Changed their eating habits (if so, how?) _______________________________________________
Review of Symptoms
Do you now or have you ever had the following?
Heart trouble/chest pain
Stomach ulcers
Diabetes (indicate if insulin dependent)
Blood diseases (anemia, other)
Abnormal Chest X-Ray (? TB)
Asthma/Emphysema/Bronchitis
Cough
Epilepsy or Seizures
Hepatitis (indicate type)
Fever or Night sweats
Change in weight (indicate gain or loss)
Bone pain (if yes, when?)
Cancer (what kind/when diagnosed?)
Positive HIV/AIDS test
Arthritis (if yes, what type?)
MRSA infection (where? When?)
Kidney disease/Bladder problems
Psychological problems
Are immunizations up to date?
Measles/Mumps/Chicken Pox
Are you or could you be pregnant?
Are you Left or Right handed?
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
L
(Please circle yes or no and explain any yes answers)
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes _________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
Yes ________________________________________________
R ________________________________________________
Patient Signature: _________________________ Reviewed by: _______________MD Date: _______________
Parent or legal guardian signature: _____________________________
HEALTH HISTORY QUESTIONNAIRE
PAGE -2Past Medical / Surgical History
List previous surgeries and approximate dates: _______________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Any abnormal reactions to anesthesia? ______________________________________________________________
_____________________________________________________________________________________________
Any hospitalizations for non-surgical condition? (What condition/When?): _________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Do you have any other chronic health conditions that we should know about? (neurofibromatosis, hepatitis, etc)
____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Family History
Any family history of significant medical illness, or cancer? (If yes, please describe problem and relationship to
you): ________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Adolescent Social History
In what type of dwelling do you live? ______________________________________________________________
Are there any siblings? No Yes (if yes, how many?) ______ Any health problems? _________________________
Are there stairs in your home? ____________________________________________________________________
Do you have any pets? No Yes (What/How many?) __________________________________________________
Do you smoke currently? No Yes
Packs per day? _________________for_________years
Quit Smoking? No Yes ______This year______>1 year ______>5 years_____ >10 years
Do you drink alcoholic beverages? _______Never
_____Occasionally
______Regularly
Do you have a history of substance abuse? No Yes (If yes, what substance)______________________________
Do you exercise? ____ Daily ____Weekly ____Monthly ____Rarely ____Never
What do you like to do for exercise? _______________________________________________________________
What do you do for fun? _________________________________________________________________________
Team Sports/Physical Education class?______________________________________________________________
Patient Signature: _________________________ Reviewed by: _______________MD Date: ______________
Parent or legal guardian signature: _____________________________
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