New Patient Information Form – Child and Adolescent

Please correct the errors described below.

Dear Parent/Guardian, please fill out completely and to your best ability, checking with records, diaries, or other means to provide as much detail as possible. If area is unclear, the physician will go over that area with you. Thanks!

Internet, doctor referral (if so, who?), etc.

Evaluation Process

Background Information Section

Living Situation

Pregnancy/Birth Information

Developmental Course

School Information

How well does the patient do in:

If Yes:

(Specify if known)
(Specify if known)

Social Information

Family Information

How well does your child get along with:

If YES, mark all that apply.

Childs Age

Approximate date/length of problem

Child’s Medical History

The following section has immune related questions. Please answer as completely as possible. If you think of information that may be relevant to your child’s history that is not on this form or parent questionnaire, please add at the end of this form

Illness/Symptoms

At what age(s)?

Currently present?

Comments

Autoimmune Diseases

Sydenham’s chorea (St. Vitus Dance)

Chorea

Rheumatic fever

Rheumatic heart disease

Lupus, Sjorgren’s

Multiple Sclerosis

Idiopathic Thrombocytopenia Purpura (low platelets)

Lyme disease/Tic bites

Kawasaki’s disease

Henoch-Schonlein purpura

Myasthenia gravis

Heart murmur

Thyroid disease: hypothyroid (Hashimoto’s thyroiditis)

Thyroid disease: hyperthyroid (Grave’s disease)

Diabetes Type 1

Psoriasis

Rheumatoid arthritis

Crohn’s disease

Inflammatory bowel disease/colitis

Other

Infectious Illness

Frequent Strep/tonsillitis

Frequent ear infections

Pneumonia

Bronchitis

Sinusitis

Scarlet Fever

Impetigo

Erythema marginatum

Any Serious Infection:

Other

Symptoms

Dizziness or Fainting

High Blood Pressure

Loss of Consciousness

Low Blood Pressure

Sleep Problems

Frequent urination

Urogenital Problems (bladder, wetting)

Nose bleeds

Skin nodules

Heart murmur

Unexplained large or dilated pupils

Joint swelling or tenderness

Vaginal redness

Erectile Dysfunction

Rectal Bleeding

Irritable Bowel Syndrome

Chronic back pain

Dysfunctional Uterine Bleeding

Irregular Menses

Pregnancy

Fatigue

Frequent Headaches

Frequent Stomachaches

Frequent diarrhea/loose stools

Constipation

Other symptom/illness

Perianal rash or vaginal strep

Circular rash (red ring)

Vision problems (e.g. Lazy eye)

Other

Surgery and Other Medical History

Head Injury

Seizures

Asthma

Allergic rhinitis

Tonsillectomy

Adenoids removed

POTS (postural orthostatic tachycardia syndrome)

Other Serious Illness

Other Serious Injury

Surgical Procedure

Surgical Procedure

Other

Immunization History

Allergies

Does your child experience any of the following when they do not have a cold or viral infection:

To which of the following is your child allergic:

Family History

Please check if your child’s “blood” family member has been diagnosed with any of the illnesses listed below. Define relationship: i.e., siblings, parents, grandparents, aunts, uncles, 1st cousins.

Diagnosed with

Psychiatric and Psychotherapy History

Please list names of clinicians that treated, problems addressed, the reason for stopping, and the response:

Add new row

Please provide copies of report if available.

Sleep/Appetite