Child English Intake - My Doctor Online The Permanente Medical ...
Child English Intake - My Doctor Online The Permanente Medical ...
Child English Intake - My Doctor Online The Permanente Medical ...
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;~ KAISERPERMANENTE..<br />
<strong>Medical</strong> HistoD:<br />
IMPRINT AREA<br />
Does the child/teenhaveanysignificantmedicallhealthproblems(e.g.asthma,diabetes,heart<br />
condition,troublewithvision,hearingor motorcontrol?) 0 No 0 Yes(pleaseexplain)<br />
------<br />
Pleasecheckif the child/teenhadanyof the following:<br />
o Mumps 0 Pneumonia 0 WhoopingCough<br />
o ScarletFever 0 Seizures 0 Multipleear<br />
infections<br />
o LeadPoisoning 0 ChickenPox Other<br />
Hasthe child/teenhad anyaccidentsresultingin the following:<br />
o Encephalitis<br />
o Measles<br />
o BrokenBones<br />
o LostTeeth<br />
0 Head Injury<br />
0 SevereBruises<br />
0 Eye Injury<br />
0 Sutures<br />
o Severe Lacerations<br />
Other_<br />
Is therea historyof 0 0 0 0<br />
o o<br />
abuse? Physical Sexual Emotional Neglect Unknown None<br />
If yes,pleaseexplain:<br />
Has there ever been any type of contact with <strong>Child</strong> Protective Services? 0 No 0 Yes (please<br />
explain)<br />
If your child has experienced a head injury, did-they lose consciousness? 0 Nohowlong?<br />
0 Yes If yes,for<br />
Does the child/teen currently have any sleep problems? 0 None<br />
o 0 0 o o<br />
Difficulty Earlymorning Restlesssleep Difficultystaying Oversleeping<br />
fallingasleep awakeni.!!g asle~<br />
Doesthe child/teenhavedifficultywithbladder/bowelcontrol?<br />
o Unknown Current: 0 No 0 Yes Past: 0 No 0 Yes<br />
--<strong>The</strong>-chiidJteen;s-appetite is:---" OL;rg~-D-Average "---"-ErsmaIler than"average <br />
than average _<br />
Hasthe child/teeneverbeenprescribedmedicationssuchas: Ritalin,Dexedrine,Anticonvulsants,or<br />
Antihistamines? 0 No 0 Yes 0 Unknown<br />
Is the child/teencurrentlyon anymedications? 0 No 0 Yes(pleaselist)<br />
Psychosocial History<br />
Pleasecheckone that describesthe child/teen'sSOCIALSKILLSwithinthe followinggrades:<br />
Preschool: 0 Poor 0 Average 0 Good 0 Unknown<br />
Kindergarten: 0 Poor 0 Average 0 Good 0 Unknown<br />
Grades 1-3: 0 Poor 0 Average 0 Good 0 Unknown<br />
Grades4-6: 0 Poor 0 Average 0 Good 0 Unknown<br />
Grades 7-12: 0 Poor 0 Average 0 Good 0 Unknown<br />
Pleasecheckone that describesthe child/teen'sPROFECIENCYTESTINGwithinthe followinggrades:<br />
Preschool: 0 Poor 0 Average 0 Good 0 Unknown<br />
Kindergarten: 0 Poor 0 Average 0 Good 0 Unknown<br />
Grades 1-3: 0 Poor 0 Average 0 Good 0 Unknown<br />
Grades4-6: 0 Poor 0 Average 0 Good 0 Unknown<br />
Grades 7-12: 0 Poor 0 Average 0 Good 0 Unknown