Children`s Specialists Pediatric Pulmonology & Sleep Medicine of

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Children's Specialists Pediatric Pulmonology & Sleep Medicine of Florida
7970 Summerlin Lakes Drice
Suite 200
Fort Myers, Florida 33907
(239) 437-5500/fax (239) 437-5507
Oscar Alea, M.D. E. Jean Baptiste, M.D. Patrick Maeng, M.D. John Reich, PA-C
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PATIENT INFORMATION FORM
Name: ___________________________________________________________________________
DOB: _______-_______-_______ AGE: ________ SEX: ____________ RACE: ____________
Name of Patient’s Pediatrician? _______________________________________________________
Fathers Name: ________________________ Mothers Name:_______________________________
Father’s Occupation: ____________________ Mother’s Occupation:_________________________
Reason for Visit: _________________________________________________________________
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Allergies: ________________________________________________________________________
NAME OF MEDICATION
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DOSE
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HOW/WHEN USE
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Any steroid use? When?_____________________________________________________________
Does your child use a Aerochamber or Nebulizer?________________________________________
Patient’s Medical History
Complications with pregnancy or labor?_______________________________________________
Full Term/Premature _____________weeks Delivery: _____ Vaginal: _____ C-section: ______
Birth Weight: __________ Birth Height: __________
___NICU Care ___Required Oxygen ___ Ventilator ___ C/BI-Pap How Long Needed ________
Other Complications at Birth: ________________________________________________________
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Current Diet: ___ Normal ___Picky ____ Special Dietary Needs____________________________
Intolerances to any foods: ___________________ Swallowing Problems: _____________________
2
When did your child first start having breathing problems? _________________________________
Check all symptoms your child has.
__Shortness of Breath __Cough (wet/dry) ___Congestion ___Noisy Breathing ___Chest Tightness
When does your child’s symptoms get worse?
__Colds __Dust __Crying __Pollution __Cleaning Chemicals/Perfumes __Running
___Early Morning ___Bedtime ___Spring ___Summer ___Fall ___Winter Other__________
How often does his symptom occur? ____Daily ____Weekly _____Monthly ___Continuously
How often has your child been hospitalized or seen in the emergency room for symptoms?
When:___________________________________________________________________________
Where:___________________________________________________________________________
Family History of Medical Problems (mother, father, grandparents, siblings of patient):
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Number of Brothers: ______ Ages: _______ Sisters: _______ Ages:________
Home Environment
Do you live : ______House ______Apartment/Condo/Duplex ______Mobile Home
Flooring in home: ______Carpet ______Wood _____Laminate _____Tile
Flooring in Child’s Bedroom: ____Carpet _____Wood _____Laminate ______Tile
Window coverings in child’s bedroom: Blinds_________ Curtains ______Valances________
Has your home ever flooded? ___Yes ___No
Any Mold/Mildew? ___Yes ___No
What kind of pillow does your child use? __________ How many stuffed animals/toys?_________
Any Animals? ________What kind?______________ How many?________ Inside/Outside_______
Exposure to tobacco? ________ (include inside/outside of home and in car) How Often?_________
Nearby industry/ Farms/ Woods/ Open fields/Lakes?______________________________________
Sleep Habits
Does your child have any trouble falling asleep?____ Does he/she have frequent awakenings?____
Restlessness during sleep? ____ Enuresis (bedwetting)? _____ Sleep walking? _____
Night terrors/ Nightmares? ______ Frequent napping during the day or while in school? _________
Problems with behavior in school? ____________________________________________________
Snoring? ______________________ Pauses with breathing during sleep?__________________
If yes to any of above please describe include onset and frequency.
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