Past Medical History Social History



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Children’s Orthopaedics of Atlanta
Name: Age: Referring:

Physician


Past Medical History Social History



Drug Allergies? Patient lives with

Immunizations up to date?  Y  N Adopted?  Yes  No


Medical Illnesses Grade in School

Previous Surgery Brothers:

Medications Sisters:

FAMILY HISTORY


(Circle all that have been diagnosed in your extended family)

Neurologic Disease Scoliosis Bone Cancer

Short Stature Heart Disease Benign Bone Tumors

Rheumatoid Arthritis

Developmental History



Length of Delivery: Vaginal Birth Weight: Hospital Stay(days):

Pregnancy Caesarean

Breech

Age @ sitting: Age @ walking:

Medical Information

If checked yes, please CIRCLE all conditions that apply

Yes No

  Unexplained weight gain or loss?

  Recent fever (above 100)

  Eczema, itching, rashes, or large birth marks?

  Eye surgery, glasses, or contact lens?

  Recurrent infection, congestion, or discharge in or from the ears/nose/throat/mouth?

  Heart murmurs, shortness of breath, high blood pressure?

  Asthma, chest pain, recurrent cough?

  Feeding problems, diarrhea, constipation, vomiting?

  Kidney or bladder infection, pain with urination, inability to control urine?

  Other joint pains, fractures?

  Seizures, head trauma, delayed age for walking or talking, attention deficit disorders, learning issues at school?

  Depression, behavioral problems, addiction?

  Any known problems with thyroid, growth hormone, diabetes?

  Bleeding problems, easy bruising, frequent nose bleeds, low blood count, sickle cell disease?

  Recurrent unexplained arm or leg swelling, bumps or knots under the arm or in the groin

  Environmental allergies, food allergies, sensitivity to costume jewelry or balloons?
If over Age 14 Menstrual History

Do you drink alcohol? Yes No (Females over age 10)

Do you use tobacco? Yes No Have you started your periods? Yes No

(smoking or chewing) If yes, how long ago?

When was you last period?



Is there a possibility you are pregnant? Yes No
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