Evergreen Pediatric Clinic
**** INTAKE AND HISTORY FORM ****
Patient’s Name: ______________________________________________________________________
Preferred Name: _____________________________________ Date of birth:_____________________
Mother’s Name: ______________________________________ Occupation:______________________
Father’s Name: ______________________________________ Occupation: _____________________
What adults reside in household(s) with patient if different than above? (specify relationship to patient):
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SOCIAL HISTORY:
Biological parent’s relationship status: Married
Divorced
Unmarried Widowed
Partnered
Person(s) (other than parents) providing majority of child’s care:________________________________
Patients over 13 years - Smoking Status (circle one):
YES
NO
Smokers among caregivers?..……………………………………………………….………………...…. Y/N
Smoke detectors in the home?..……………………………………….………………………….….…... Y/N
If firearms in the home, are they locked? ……………………………………………………………….. Y/N
Primary source of drinking water fluoridated? ................................................................................ Y/N
Established with a dentist? ……………………………………………………………………………….. Y/N
SIBLINGS:
Name:________________________________ Date of birth:__________________________________
Name:________________________________ Date of birth:__________________________________
Name:________________________________ Date of birth:__________________________________
Name:________________________________ Date of birth:__________________________________
ALLERGIES:
Please list any allergies to the following:
Medications: ________________________________ Type of reaction: _________________________
Foods: _____________________________________ Type of reaction: _________________________
Insect bites: _________________________________ Type of reaction: _________________________
Environmental:_______________________________ Type of reaction: _________________________
PRESCRIBED or OVER THE COUNTER MEDS, SUPPLEMENTS and/or VITAMINS:
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HOSPITALIZATIONS & SURGERIES (date and hospital):
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FAMILY MEDICAL HISTORY
***Please mark conditions diagnosed by a medical provider***
PLEASE SPECIFY FAMILY MEMBERS
(brother, sister, maternal or paternal grandmother or grandfather)
CONDITIONS
PATIENT’S
MOTHER
PATIENT’S
FATHER
PATIENT’S
SIBLING(S)
PATIENT’S
GRANDPARENTS
PATIENT’S
AUNT or UNCLE
ADD
Allergies
Anemia
Anxiety
Asthma
Birth defects
Cancer
Depression
Developmental delay
Diabetes (specify Type I or II
Hearing loss
Heart attack (before 50)
High blood pressure (before 50)
High cholesterol (before 50)
Migraines
Hepatitis (specify A, B, or C)
Seizure disorder
Sudden death (before 50)
Thyroid disorder
Urinary infections (chronic)
Please list any significant diagnoses not noted above and/or additional details of family history:
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PATIENT’S PAST MEDICAL HISTORY
*** Please mark conditions diagnosed by a medical provider ***
IMMUNE SYSTEM:
Chicken Pox Disease……………..……………………………………………...……………….. Y/N
Immune disorders…………………………………………………………………..……………… Y/N
EYE, EARS, NOSE AND THROAT:
Chronic ear infections ……………………………………………….……………………………. Y/N
Sleep apnea ……………………………………….………….………..………………..………… Y/N
Hearing loss (diagnosed) ……………...……………………………………..….…….…..…….. Y/N
Seasonal allergies………………………………………………………………..……………..…. Y/N
Visual disturbance……………………………………………………………...…………………. Y/N
RESPIRATORY:
Asthma………………………………………………………………………………...……………. Y/N
Croup (recurrent)…………………………………………………………………….........………. Y/N
RSV infection…………………………………………………………………………...………...... Y/N
Pneumonia……………………………………………………………………….…..................... Y/N
CARDIOVASCULAR:
Heart murmur (evaluated by cardiologist)………………..………………….……….…......….. Y/N
High blood pressure....……………………………………..…………………….....………..…... Y/N
DIGESTIVE:
Gastroesophogeal reflux (GERD) …………….………...…………………...………………..... Y/N
Constipation (chronic)…………………………..…………………..…………………………….. Y/N
Diarrhea (chronic)……………………………………………….…………….……………….….. Y/N
UROLOGIC:
Recurrent urinary/bladder/kidney infections…………………………………….…………...…. Y/N
Boys only: Circumcised………………………………………………………..……..…….......... Y/N
Girls only: Age of first menstrual cycle ______
ENDOCRINE:
Poor growth/slow weight gain……………………………………………….…….……………... Y/N
Excessive weight gain……………………………………………….……………………………. Y/N
Thyroid dysfunction…………………………..……………………………….……….…….……. Y/N
Diabetes…………………………………………………………………………….…………….... Y/N
HEMATOLOGY:
Anemia……………………………………………………………………...……….……………… Y/N
Bleeding disorder………………………………………………………………….………………. Y/N
NEUROLOGIC:
Seizure disorder…………………………………………………….…………….…………….…. Y/N
Migraines……………………………………………………………………….……….………..… Y/N
Cerebral Palsy…………………………………………………………………….…………..…… Y/N
Developmental delays…………………………………………………………….…………..….. Y/N
MUSCULOSKELETAL:
Fracture (broken bone)………………………………………………………………...............… Y/N
If yes, location of fracture:________________________
Bone/Joint infection………………………………………………………………......……..…….. Y/N
Scoliosis……………………………………………………………………………….……………. Y/N
SKIN:
Eczema…………………………………………………………………………………....………... Y/N
Psoriasis…………………………………………….……………………………………….…..…. Y/N
Please list any other significant diagnoses not listed on previous pages:______________
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***PLEASE REMEMBER TO BRING IMMUNIZATION RECORD TO ALL APPOINTMENTS**
Signature of person who completed form:_____________________________________
Relationship to patient: ______________________________ Date: ________________