Pediatric Registration Pediatric New Patient Form Step 1 of 7 14% General InformationChild's Name* First Last DOB* Age*MR#Pediatrician's Name*Pediatrician's AddressPhone*Were you referred from another doctor?*YesNoWhat is the name of the doctor who referred you to us?*Explain the reason for your visit Past Medical HistoryBirth WeightBirth LengthPlace of BirthWas the birth full term or premature?Full TermPrematureLabor/DeliveryVaginalC-SectionDescribe any problems with the birth Describe any problems within the first month of life List all medications and their dosage/frequency (include over the counter and herbal therapies and vitamins) Allergies? Drugs Food Other Describe the allergies List any medical problems your child has List any hospitalizations that your child has had. Include his/her age, where hospitalized, and the reason for the hospitalization Are immunizations up to date?YesNoList any surgeries/procedures with the dates performed that your child has had. Include those done as an outpatient or state “none”. Family HistoryHas anyone in the patient’s family (or relative) had any of the following? Migraine headaches Seizures Mental or developmental delay Asthma, Emphysema Cystic Fibrosis Sickle cell disease or trait Cancer Heart disease or stroke Diabetes Anemia High cholesterol Constipation Polyps Gallstones/gall bladder problem Gastritis/ulcer Colitis, Crohn’s disease Celiac disease Liver problems Blood in stool Irritable bowel syndrome If you checked any of the above, for each one you checked, please tell us what your relation was to that family memeber In response to the above, which type of cancer was it?Is there any other disease/illness that runs in the family?YesNoPlease describe Social HistoryWho lives with the patient? Please include the name, age, relationship and health problems for each person. The child's parents areSingleMarriedDivorcedSeparatedRemarriedCurrent Grade in SchoolPre-KKindergartenGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8Grade 9Grade 10Grade 11Grade 12Performance/Grades/GPAHas there been any recent change in behaviour?YesNoIf you answered "Yes" above, please explain: Any unusual stresses at home?YesNoIf you answered "Yes" above, please explain: Review of Systems: Please check any of the following that are problems for your child:General Recurrent fevers/temperatures Weight loss Weight gain Heart/ Blood vessels Heart murmur Heart problems Chest pain Palpitations (fast heart beat) Irregular heart beat Blood pressure problems Breathing/ Lungs/ Chest Coughing Wheezing Asthma Shortness of breath Apnea (stops breathing) Pneumonia Skin Skin rashes Acne Easy bruising Ears, Nose, Throat Ear pain Ear infections Discharge from ears Nose bleeds Sinus problems Mouth Ulcers Trouble swallowing Hoarseness Sour taste in mouth Sore throat Dental problems Unusual infections Genital/Urinary System Pain/burning with urination Blood in urine Increased frequency or amount of urine Swelling/retaining water Other urinary tract or kidney problems Menstrual problems Age at first menstrual period (if applicable)Date last menstrual period ended (if applicable) Breasts Discharge from nipples Breast lumps/masses Other skin problems Musculoskeletal Joint problems Weakness Scoliosis (curved spine) Endocrine (Glands) Thyroid problems Poor growth Other hormone/gland problems Allergy/Immune System Allergies Immune problems Frequent infections Gastrointestinal (Stomach / Intestines) (Blood problems) Constipation (hard or infrequent stools) Soiling underpants Diarrhea Vomiting/spitting up Heartburn Blood in stool Difficulty swallowing Stomach pain Nausea Liver problems/jaundice/hepatitis Neurologic (Brain / Nerves) Developmental delay Headaches Seizures Dizziness Fainting ADHD (hyperactivity) Decreased sensation Decreased muscle strength Other neurologic problems Hematologic Anemia Received blood transfusions Easy bruising Swollen lymph nodes Bleeding disorders/ bruising Feeding HistoryHow was your child fed as an infant?Breast FedBottle FedIf breast-fed, for how long? What formula did (does) your child receive?Is your child on a special or restricted diet? YesNoIf you answered "Yes" above, please describe: Is your child’s appetite normal or decreased? NormalDecreased Bowel HistoryDid your child pass meconium (stool) while in the nursery in the first 24-48 hours of life?YesNoDid your child have normal stooling as a baby?YesNoHow often does your child stool now? When was your child’s last bowel movement? Does your child have accidents (soils underpants)? YesNoIs your child’s stool malodorous (smells awful)? YesNoWhat is the consistency of your child’s stool? HardSoftLooseWateryWhat is the consistency of your child’s stool? BrownYellowGreenOrangeRedBlack Δ
