Goodman Pediatrics

Child's Name

Today's Date

Date of Birth

Pharmacy

Last WCC

Dentist

Orthodontist

Please list any other doctors involved in care
(for example, specialists including GI, allergy, psychologist or others)

Doctor's Name and Specialty

Add a new Doctor/Specialty

Medications prescribed by other doctors

Any recent x-rays?

Yes No

If 'Yes', where was it done?

Any recent bloodwork?

Yes No

If 'Yes', where was it done?

Who does your child live with?

Any changes in living arrangements in the past year? (includes separation or divorce of parents, remarriage, emancipation of child)

Yes No

If 'Yes', explain:

Signifigant health events for family members in the past year? (includes hospitalizations, surgeries, new medical diagnosis, deaths, mental health of substance use and/or any other stressful event(s))

Yes No

If 'Yes', explain:

Are there any smokers in the household?

Yes No

Does your child need to turn the TV volume up higher than others?

Yes No

Does your child have to strain to understand a conversation?

Yes No

Does your child misunderstand and respond inappropriately?

Yes No

Does your child have trouble hearing on the telephone?

Yes No

Does your child have a parent or grandparent with heart bypass surgery, angina, stroke, vascular disease, or sudden death younger than age 55?

Yes No

Does your child have a parent or grandparent with cholesterol over 240 or who takes medication for high cholesterol?

Yes No

Tuberculosis Exposure

Has your child visited Africa, Latin America or Eastern Europe in the last year?

Yes No

Has your child been exposed to anyone with Tuberculosis?

Yes No

Has your child had close contact with anyone with a positive TB skin test (PPD)?

Yes No

Does your child have a household member that travels outside the US?

Yes No

Does your child have close contact with anyone who has been in prison, a shelter, a nursing home, that uses illegal drugs or has HIV/AIDS?

Yes No

Signature of Parent/Guardian

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