NEW PATIENT FORM - OU Medicine
NEW PATIENT FORM - OU Medicine
NEW PATIENT FORM - OU Medicine
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<strong>NEW</strong> <strong>PATIENT</strong> <strong>FORM</strong><br />
Please print in ink and fill in all blanks<br />
Please fill out front and back<br />
Patient’s Full Name_____________________________________________________________________<br />
Date of Birth________________ Age_______________ Sex_______________________<br />
Social Security Number____________________<br />
Referring Doctor or Family Physician_______________________________________________________<br />
Phone #_____________________________________ Fax #___________________________________<br />
Address______________________________________________________________________________<br />
Father’s Full Name_____________________________________DOB____________________________<br />
Address______________________________________________________________________________<br />
Education______________________________Occupation_____________________________________<br />
Home Phone #_____________________________ Work Phone #________________________________<br />
Mother’s Full Name____________________________________________________________________<br />
Address ______________________________________________________________________________<br />
Education______________________________Occupation_____________________________________<br />
Home Phone #_____________________________ Work Phone#________________________________<br />
Best number to contact parent is__________________________________________________________<br />
Party bringing child to appointment________________________________________________________<br />
Siblings:<br />
Name: Age Health Problems<br />
______________________________________ _____ __________________________<br />
______________________________________ _____ __________________________<br />
______________________________________ _____ __________________________<br />
______________________________________ ______ __________________________
Health History<br />
Patient______________________________________<br />
Date_______________________<br />
Reason for visit: _______________________________________________________________________<br />
_____________________________________________________________________________________<br />
Date symptoms first occurred ____________________________________________________________<br />
Are symptoms continuous? Yes _____ No______<br />
If NO please list dates and details: _________________________________________________________<br />
_____________________________________________________________________________________<br />
Please list any blood work done or tests previously performed: _________________________________<br />
_____________________________________________________________________________________<br />
Please have the following Information below available at your next appointment<br />
Current Medications Dosage Time Given<br />
_______________________________ __________ ___________________<br />
_______________________________ __________ ___________________<br />
_______________________________ __________ ___________________<br />
_______________________________ __________ ___________________<br />
Past Medication tired for present condition: ________________________________________________<br />
Was Child hospitalized for above condition?: ________________________________________________<br />
PAST MEDICAL HISTORY<br />
Is this child yours by: Birth_______ Adoption: _______ Step child_______ Other________<br />
PREGNANCY<br />
Mother’s totally # of pregnancies_______ Number of Living Children _______<br />
Mother’s total # of Abortions_______ Number of Miscarriages_________<br />
Pregnancy with this patient was Normal? Yes _______ No _______<br />
If NO please explain ____________________________________________________________________<br />
_____________________________________________________________________________________<br />
Were any drugs or medications used during the Pregnancy? Yes_______ No_______<br />
If YES please list________________________________________________________________________<br />
BIRTH HISTORY<br />
Birth Wt______ Birth Length ______ APGAR SCORES_____ _____ Length of Pregnancy_______<br />
Type of delivery: Vaginal____ C-Section____ Planned____ Emergency _____<br />
Did child have any complications during or immediately following birth: Yes___ No _____<br />
If YES Please explain _____________________________________________________________<br />
______________________________________________________________________________<br />
Developmental Milestones
Age child rolled over___________________ Spoke first words______________________<br />
Sat up _____________________________ spoke in sentences____________________<br />
Crawled_______________________<br />
Potty trained_________________________<br />
Cruised_______________________<br />
Walked_____________________________<br />
Is your child’s social development normal: Yes___ No___ If NO please describe (introverted,<br />
extroverted, aggressive, etc.)______________________________________________________<br />
______________________________________________________________________________<br />
Is your child’s educational development normal? Yes____ No ___ If NO please describe<br />
(Regular ed., Special ed. etc)<br />
_______________________________________________________<br />
______________________________________________________________________________<br />
Is your child physical development normal? Yes_____ No______ If NO please describe (fine<br />
motor skills, walking, running, etc.)_________________________________________________<br />
______________________________________________________________________________<br />
Medical History<br />
Medical<br />
Date of onset<br />
Anemia ___________ Hydrocephalus ____________<br />
Arthritis ___________ Leukemia ____________<br />
Asthma ___________ Meningitis ____________<br />
Bleeding Disorders ___________ Migraines ____________<br />
Cerebral Palsy ___________ Pneumonia ____________<br />
Concussion ___________ Psychology history ____________<br />
Congenital heart Abnormality___________ Seizures ____________<br />
Diabetes ___________ Skeletal Disorders ____________<br />
Growth Abnormalities ___________ Other ____________<br />
Hospitalizations/ Operations (with age)______________________________________________<br />
Family Members Health History<br />
Does anyone in your family have or have a history of<br />
Cardiac Disease _____________ Strokes ____________<br />
Depression _____________ Seizures ___________<br />
Drug Addiction _____________ Seizures with fever___________<br />
Eye Disease _____________ Slow Development____________<br />
Migraines _____________ Schizophrenia _____________<br />
Manic Depression _____________ Panic Attacks ______________<br />
Muscle Disease _____________ Violent Behavior _______________<br />
Nerve Disease _____________<br />
Review of Systems<br />
General YES COMMENTS
Fatigue _____ _________________<br />
Joint pain/ muscle pain _____ _________________<br />
Weight gain _____ _________________<br />
Weight Loss _____ _________________<br />
Change in appetite _____ _________________<br />
Night Sweats _____ _________________<br />
Fever/ Chills _____ _________________<br />
Eyes<br />
Do you wear glasses? _____ _________________<br />
Eye Problems _____ _________________<br />
Lazy Eye _____ _________________<br />
Ears/ Nose/ Throat and Mouth<br />
Earache/ drainage _____ __________________<br />
Sore Throat _____ __________________<br />
Teeth/ gum problems _____ __________________<br />
Hearing Loss _____ __________________<br />
Nasal Allergies _____ __________________<br />
Nose bleeds _____ __________________<br />
Respiratory<br />
Cough _____ __________________<br />
Shortness of breath _____ __________________<br />
Wheezing _____ __________________<br />
Cardiovascular<br />
Chest pain ______ __________________<br />
Congenital heart defect ______ __________________<br />
Irregular heart beat ______ __________________<br />
Gastrointestinal<br />
Difficulty in swallowing ______ __________________<br />
Vomiting ______ __________________<br />
Nausea ______ __________________<br />
Food Intolerance ______ __________________<br />
Diarrhea ______ __________________<br />
Constipation ______ __________________<br />
Abdominal pain ______ __________________<br />
Genital-Urinary<br />
Problems with urination _____ ___________________<br />
Bedwetting _____ ___________________
Painful urination _____ ___________________<br />
Kidney Stones _____ ___________________<br />
Recurrent bladder or<br />
Urinary Tract Infections ______ ___________________<br />
Irregular period ______ ___________________<br />
Skin<br />
Change in hair and nails ______ ___________________<br />
Birthmarks ______ ___________________<br />
Rashes ______ ___________________<br />
Lumps or growths ______ ___________________<br />
Change in skin color ______ ___________________<br />
Endocrine<br />
Hormone problems _______ ___________________<br />
Temperature intolerance _______ ___________________<br />
Diabetes _______ ___________________<br />
Thyroid disease _______ ___________________<br />
Hematology/ Lymphatic<br />
Anemia _______ ___________________<br />
Bleeding or bruising tendencies _______ ___________________<br />
Blood clotting disorder _______ ___________________<br />
Past transfusions _______ ___________________<br />
Allergic/ Immunologic<br />
Hay fever _______ ___________________<br />
Hives _______ ___________________<br />
Itching _______ ___________________<br />
Allergies or drug reactions _______ ___________________<br />
Food allergies _______ ___________________<br />
Psychiatric<br />
Anxiety _______ ___________________<br />
Depression _______ ___________________<br />
Memory loss _______ ___________________<br />
Short attention span _______ ___________________<br />
Confusion _______ ___________________<br />
Parent/ Guardian Signature ____________________________________________
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