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 _________________________________________________________________________________ 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: _________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Allergies: ________________________________________________________________________ NAME OF MEDICATION _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ DOSE ____________ ____________ ____________ ____________ ____________ ____________ HOW/WHEN USE ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ 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: ________________________________________________________ ________________________________________________________________________________ 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): _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 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. _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________