Patient Name LMale

LFemale Date of Birth

Date of last physical exam: _________________________________________________________________________ Weight: ______________________ Name/address/phone number of primary physician: ___________________________________________________________________________________ Name/address/phone number of medical specialists: ___________________________________________________________________________________ Is your child being treated by a physician at this time? Reason ________________________________________________________ iYES iNO Is your child taking any medication (prescription or over the counter), vitamins, or dietary supplements? List name, dose, frequency & date started _______________________________________________________________________

iYES iNO

Has your child even been hospitalized, had surgery or a signi cant injury, or been treated in an Emergency Department.................... List date & describe ________________________________________________________________________________________

iYES iNO

Has your child ever had a reaction to or a problem with an anesthetic? …………………... ……………….……………………..……… Describe: ________________________________________________________________________________________________

iYES iNO

Has your child ever had a reaction or allergy to an antibiotic, sedative, �uoride, or other medication? ..........……………...………… List ____________________________________________________________________________________________________

iYES iNO

Is your child allergic to latex or anything else such as metals, acrylic, or dye? ……………………………………………..…………... List ____________________________________________________________________________________________________

iYES iNO

Is your child allergic to tree nuts, soy, Birch trees, etc.? ………………………………………………………………….………….…... List _____________________________________________________________________________________________________

iYES iNO

Is your child up to date on immunizations against childhood diseases ……………………………………………………... …...…… iYES iNO

Mark NO after each line if none of those conditions apply to your child. Please mark YES if your child has a history of the following conditions. For each “YES,” provide details in the box at the bottom of this list.

Complications before or during birth, prematurity, birth defects, syndromes or inherited conditions ………………...… iYES iNO Problems with physical growth or development …………………………………………………………………………. iYES iNO Sinusitis, chronic adenoid/tonsil infections ………………………………………………………………………………. iYES iNO Large tonsils, sleep apnea/snoring, mouth breathing, or excessive gagging ……………………………………. iYES iNO Congenital heart defect/disease, heart murmur, rheumatic fever, or rheumatic heart disease …………………………… iYES iNO Irregular heart beat or high blood pressure ………………………………………………………………………………. iYES iNO RSV, Asthma, reactive airway disease, wheezing, or breathing problems ……………………………………………... iYES iNO Frequent colds or coughs, or pneumonia ………………………………………………………………………………… iYES iNO Is there anyone in the child’s life who smokes? ………………………………………………………………………… iYES iNO Jaundice, hepatitis, or liver problems …………………………………………………………………………………….. iYES iNO Gastroesophageal/acid re ux disease (GERD), stomach ulcer, or intestinal problems ………………………………….. iYES iNO Lactose intolerance, food allergies, nutritional de ciencies, or dietary restrictions …………………………………... iYES iNO Prolonged diarrhea, unintentional weight loss, concerns with weight, or eating disorder ……………………………….. iYES iNO Bladder or kidney problems ……………………………………………………………………………………………… iYES iNO Arthritis, scoliosis, limited use of arms or legs, or muscle/bone/joint problems ………………………………………… iYES iNO Rash/hives, eczema or skin problems ……………………………………………………………………………………. iYES iNO Impaired vision, hearing or speech ………………………………………………………………………………………. iYES iNO Developmental disorders, learning problems/delays, or intellectual disability ………………………………………….. iYES iNO Cerebral palsy, brain injury, epilepsy, or convulsions/seizures ………………………………………………………….. iYES iNO Autism/autism spectrum disorder ………………………………………………………………………………………… iYES iNO Recurrent or frequent headaches/migraines, fainting, or dizziness ………………………………………………………. iYES iNO Hydrocephaly or placement of a shunt (ventriculoperitoneal, ventriculoatrial, ventriculovenous) ………………… iYES iNO Attention de cit/hyperactivity disorder (ADD/ADHD) …………………………………………………………………. iYES iNO Behavioral, emotional, communication, or psychiatric problems/treatment …………………………………………….. iYES iNO Abuse (physical, psychological, emotional, or sexual) or neglect ……………………………………………………….. iYES iNO Diabetes, hyperglycemia, or hypoglycemia ……………………………………………………………………………… iYES iNO Precocious puberty or hormonal problems ………………………………………………………………………………. iYES iNO Thyroid or pituitary problems ……………………………………………………………………………………………. iYES iNO Anemia, sickle cell disease/trait, or blood disorder ……………………………………………………………………… iYES iNO Hemophilia, bruising easily, or excessive bleeding ……………………………………………………………………… iYES iNO Transfusions or receiving blood products ………………………………………………………………………………... iYES iNO Cancer, tumor, other malignancy, chemotherapy, radiation therapy, or bone marrow or organ transplant ………....... ... iYES iNO Mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus (CMV), methicillin resistant staphylococcus aureus (MRSA), sexually transmitted disease (STD), or human immunode ciency virus (HIV)/AIDS …………… ..…………

iYES

iNO

PROVIDE DETAILS HERE: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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Dr. GremillionNew Patient Medical History-Form

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