G.J. Gelpi, M.D. D.R. Vick, M.D. |
THE PEDIATRIC CLINIC 888 Tara Boulevard Baton Rouge, Louisiana 70806 Telephone: 225-926-4400 Fax: 225-926-4409 HEALTH QUESTIONAIRE |
S. M. Kelleher, M.D. G.J. Schwartzenburg, M.D. |
| Name: __________________________________ Date of Birth: __________________________________ |
| Previous Physician: _______________________ |
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| Hospitalizations | Y N | Surgeries | Y N | |
| Serious Accidents | Y N | Fractures | Y N | |
| Chronic Illnesses | Y N | Skin Diseases or Rashes | Y N | |
| Urinary Tract Infections | Y N | Seizures | Y N | |
| Chicken Pox | Y N | Vision Problems | Y N | |
| Hearing Problems | Y N | Ingestion of Non-Food Items | Y N | |
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| Birth History |
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Birth Weight:________________ |
Birth Height: __________________ |
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| Place of Birth:____________________ | Duration of Hospitalization:____________________ | |||
| Illness During Pregnancy | Y N | Explanation of Illness:________________________ | ||
| Respiratory Problems | Y N | Explanations of Problems:_____________________ | ||
| Feeding History | Breast:____________ Formula:____________ | |||
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| Significant Family History:__________________________________________________________________ | ||||
| Circle all that apply | ||||
| Miscarriages Tuberculosis | Asthma | Diabetes Eye Problems | Seizures | |
| Cardiac Disease Bleeding Problems | Renal Disease | Sickle Cell Disease Hypertension | Anemia | |
| Depression | ||||
| Mother's age/Name:_________________ Health:________________ Occupation:__________________ | ||||
| Father's age/Name:__________________ Health:________________ Occupation:__________________ | ||||
| Sibling's age/Name:______________________ | Health:____________________________ | |||
| Sibling's age/Name:______________________ | Health:____________________________ | |||
| Sibling's age/Name:______________________ | Health:____________________________ | |||
| Sibling's age/Name:______________________ | Health:____________________________ | |||
| With whom does the patient live? ____________________________________________________________ | ||||
| Additional caretakers? ____________________________________________________________________ | ||||
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| Current Medications:______________________________________________________________________ | ||||
| Medication Allergies:________________________________________________________ | ||||
| Immunizations UTD | Y N | |||
| OB/GYN:_________________________________________________ | ||||