Pediatric Surgical Services, Inc.
New Patient Medical History Questionnaire
To assist us in caring for your child, please complete the following questionnaire
Why are you here today?
What has been done thus far for this problem? (i.e. lab tests, X-rays, ultrasounds, MRT, CT, VCUG, medications)
HISTORY OF PATIENT'S BIRTH
Ended early, @ ________________
Full Term
wks. Gestation
Vaginal
Scheduled C-section
No
Yes
Please explain:
No
Yes
What?
Mother's pregnancy with patient
was:
Delivery was:
Complicated pregnancy or delivery?
Medications taken while pregnant?
Hospitalizations
Surgeries
Blood Transfusions
Contagious
Disease
Psychological Care
Is child still
receiving
psychological care?
No
No
No
Yes
Yes
Yes
When?
When?
When?
No
No
Yes
Yes
What?
When?
No
Yes
By whom?
Emergency C-Section
PAST MEDICAL HISTORY
Where?
Why?
Where?
Why?
Where?
Where?
Where?
Why?
CHILDS FAMILY HISTORY
Have any blood-related patient, sibling, grandparent, aunt, uncle or cousin of the patient had problems concerning:
Anesthetic
Asthma
Bleeding
Cancer
Developmental
delays
Diabetes
Heart Disease
Liver or kidney
disease
Seizures
Tuberculosis
Bedwetting
Other
No
No
No
No
Yes
Yes
Yes
Yes
Who?
Who?
Who?
Who?
Deceased?
Deceased?
Deceased?
Deceased?
No
No
No
No
Yes
Yes
Yes
Yes
Age:
Age:
Age:
Age:
No
No
No
Yes
Yes
Yes
Who?
Who?
Who?
Deceased?
Deceased?
Deceased?
No
No
No
Yes
Yes
Yes
Age:
Age:
Age:
No
No
No
No
Yes
Yes
Yes
Yes
Who?
Who?
Who?
Who?
Deceased?
Deceased?
Deceased?
Deceased?
No
No
No
No
Yes
Yes
Yes
Yes
Age:
Age:
Age:
Age:
SOCIAL HISTORY
Patient's parents are:
Who does patient live with?
Attends school?
Other
Rev. 5/07
Married
Unmarried
No
Yes
Divorced
Grade:
Separated
Widowed (one parent is deceased)
School:
New Patient Medical History Questionnaire
Page 1 of 2
CURRENT MEDICATIONS
Homeopathic or Natural Remedies/vits
1.
2.
3.
4.
Medication and dose
1.
2.
3.
4.
REVIEW OF SYSTEMS
Has the patient had any problems with:
HEENT (head/eyes/ears/throat)
Headaches
Eyes
Ears
Nose
Swollen glands
Sinus problems
Pulmonary (lungs)
Asthma/Wheezing
Persistent Cough
Shortness of Breath
Cardiac (heart)
Heart defect(s)
Skin turning blue
Heart murmur(s)
Palpitations
GI (digestive system)
Stomach
Constipation
Diarrhea
Nausea/Vomiting
Allergies
Endocrine (hormonal system)
Excessive appetite
Excessive thirst
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Yes
Yes
Yes
Yes
No
Yes
Musculoskeletal (muscle and bone)
Muscles
Bones
Arms
Legs
Hips
Back
Feet
Hematologic/Lymph (blood)
Clotting problems
Bleeding problems
Bruising easily
Neurologic (nervous system)
Head Injury
Seizures
Psychological
Depression
Anxiety/nervousness
Sleep disorder
Integumentary
Poor wound healing
Rashes
To what?
No
No
Yes
Yes
Weight problem
Cold/heat intolerance
______________________________________ _____________________
Provider Signature
Date
Date
Reviewed
Prov.
Initials
Date
Reviewed
Prov.
Initials
Date
Reviewed
Prov.
Initials
Date
Reviewed
Prov.
Initials
Note: Changes to ROS, medical, family and social history is documented in progress note.
Rev. 5/07
New Patient Medical History Questionnaire
Page 2 of 2
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes