New Patient Questionnaire - Helen DeVos Children's Hospital

Questionnairenew patient -pediatric pulmonaryand sleep medicineclinicPage 1 of 4Patient NameDOBMRNPhysicianFINPatient nameDate of birthSex: Male Female Age Grade Appointment dateReferring PhysicianMother's name/Legal guardianOccupationFather's name/Legal guardianOccupationBriefly describe reason for the visitMedicinesList all medicines your child is currently taking, including non-prescription or herbal therapies:M E D I mediCine dose HOW OFTEN TAKENConfidentiality of this medical record shall be maintained except when use or disclosureis required or permitted by law, regulation, or written authorization by the patient.IMMUNIZATIONSAre your child's immunizations up to date? No YesDid your child get an influenza vaccine this season? No YesDid your child get a Respiratory Syncytial Virus (RSV) this season? No YesPREFERRED PHARMACYNamePhone numberAddressPREFERRED MEDICAL EQUIPMENT COMPANYNamePhone numberAddressdo not mark below this line barcode zone do not mark below this lineover X15300 (6/12) – Page of 4*X15300*

new patient - pediatric pulmonary and sleep medicine clinic (CONTINUED)Page 2 of 4MEDICAL HISTORYHas your child ever had any of the following?Abnormal chest x-ray No YesAllergies No YesAnemia No YesAsthma No YesBee sting/Insect No YeshypersensitivityBronchiectasis No YesChronic bronchitis No YesCoughing up blood No YesDevelopmental delay No YesDiabetes No YesDown's syndrome No YesDysphagia No YesEpilepsy/Seizures No YesEczema No YesFood allergies No YesFrequent ear infections No YesGastrointestinal reflux No YesHeart problems No YesHives No YesHigh blood pressure No YesHeart problems No YesNeuromuscular problems No YesObesity No YesPneumonia No YesPoor weight gain No YesPremature No YesPulmonary embolism/Blood clot No YesTuberculosis No YesSleep apnea No YesOther medical historyList any other doctors or therapists involved in your child's careAllergistSYMPTOMS Answer if your child has had any of the following symptoms. Indicate the number of days inthe past month with symptoms, the severity of symptoms and if the symptom changed over the course ofthe year.How many daysin the past month Severity of symptoms Symptoms changed?Sneezing Mild Moderate Severe Changes by seasons? No YesWhen they are worseNasal congestion Mild Moderate Severe Changes by seasons? No YesWhen they are worseItchy nose Mild Moderate Severe Changes by seasons? No YesWhen they are worseItchy eyes Mild Moderate Severe Changes by seasons? No YesWhen they are worseCoughing Mild Moderate Severe Changes by seasons? No YesWhen they are worseWheezing Mild Moderate Severe Changes by seasons? No YesWhen they are worseCoughing/wheezing Mild Moderate Severe Changes by seasons? No Yeswith excerciseWhen they are worseCoughing/wheezing Mild Moderate Severe Changes by seasons? No Yesat nightWhen they are worseHeadaches Mild Moderate Severe Changes by seasons? No YesWhen they are worseX15300 (6/12) – Page of 4continue to next page Confidentiality of this medical record shall be maintained except when use or disclosureis required or permitted by law, regulation, or written authorization by the patient.

new patient -pediatric pulmonaryand sleep medicineclinic (CONTINUED)Page 3 of 4Patient NameDOBMRNPhysicianFINPrevious evaluationList approximate date and results, if obtainedChest x-raysSinus x-raysUpper gastrointestinal x-rayAllergy testingSweat chloride (for cystic fibrosis)Immune studiesSwallowing studyNote: Bring actual films for x-rays with you to your child's clinic visit.Surgical history with datesAdenoidectomy? No Yes on Bronchoscopy? No Yes onCircumcision? No Yes on Ear tubes? No Yes onGastric tube? No Yes on Lobectomy? No Yes onNissen Fundoplication? No Yes on Sinus surgery? No Yes onTonsillectomy? No Yes on Other? No Yes onRelationship Name AGEM=MaternalP=PaternalAsthmaCystic fibrosisAllergiesGERDObstructivesleep apneaTuberculosisImmunodeficienciesHeart diseasePulmonaryfibrosisSarcoidosisEmphysemaEczemaSinusitisRestless legsyndromeNarcolepsySleep problemsAnxietyEpilepsyConfidentiality of this medical record shall be maintained except when use or disclosureis required or permitted by law, regulation, or written authorization by the patient.MotherFatherSisterBrotherM AuntM UncleP AuntP UncleM GrandmotherM GrandfatherP GrandmotherP GrandfatherOtherTobacco Use Did the mother smoke during pregnancy No YesIf the patient is 12 years or older, answer below: If patient is less than 12 years old, answer below:Does your child smoke? No YesIs your child exposed to passiveNumber of yearstobacco smoke? No YesPacks per dayHow many care givers smoke?Tobacco: Cigarettes? No YesChewing tobacco?X15300 (6/12) – Page of 4No Yesover

new patient - pediatric pulmonary and sleep medicine clinic (CONTINUED)Page 4 of 4Other Social HistoryDoes your child live with his/her parents(s)? No Yes Who lives in the home?Is your child adopted? No Yes Is so, at what age?Does your child attend school? No Yes Does patient attend daycare? No YesList name of school/daycare and gradeDoes your child require Special Education services? No YesIf yes, explainHas your child experienced new family issues? (i.e. divorce, death, etc.) No YesIf yes, explainPets: Number of cats Number of dogs Number of birdsOther Do the pets come inside? No YesAre there farms/stables nearby? No YesHas the patient traveled outside of Michigan in the last year? No Yes If yes, where toEnvironmental Historyhome(s) your child lives inType of home: Apartment Duplex Mobile Home HouseAge of home(s) years Type of heating (forced air, steam, electric, etc.)Air conditioner? No Yes Air purifier? No Yes Basement? No YesMany indoor plants? No Yes Dust problems? No Yes Cockroaches? No YesFireplace? No Yes Wood stove? No Yes Stuffed furniture? No YesCurtain/drapes? No Yes Stuffed animals? No Yes Dampness/mold/mildew? No YesOther source of irritants (shop, hobbies, etc)? No YesChild's bedroom:Carpet? No Yes Number of beds in your child's roomFeather pillow/comforter? No Yes Allergen-proof covers for mattress? No YesPillow? No Yes Allergen-proof covers for box springs? No YesBIRTH INFORMATIONBirth hospitalBirth length Birth weight Birth head circumferenceBirth length Birth weight Birth head circumferenceWeight when discharged from hospitalGestational ageDelivery method If c-section, why? Duration of laborFeeding (breast/formula)Additional birth informationDid child go home with mother? Yes No If no, why?Name of person completing the formDateSignatureConfidentiality of this medical record shall be maintained except when use or disclosureis required or permitted by law, regulation, or written authorization by the patient.X15300 (6/12) – Page of 4