New Patient form (Pediatric)

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Patient Name*

Date of Birth:*

Sex:*

Tel #:*

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code

How did you hear about Penn Medicine Becker ENT & Allergy?*

Date*

Primary care Doctor*

Primary Care Physician's address:*

PCP phone number:*

Name of pharmacy:*

Pharmacy address:*

Pharmacy phone number:*

Please complete this form so we can facilitate your care or provide resource information regarding available services. If you are offended by the personal nature of the question content, you do not have to answer.

CHEIF COMPLAINTS Please list all reason(s) for your child's visit:*

HISTORY OF PRESENT ILLNESS

How long have these problems been present and when did they start?*

Rate severity of the problem on a scale of 1 to 10:*

What types of activities aggravate this/these problems?*

What makes these symptoms better?*

What types of treatments/medications has your child received for this/these problems? Have they helped?*

MEDICATIONS:

Is your child taking any medication, drugs, or pills?*

Yes

If yes, please list names and dosage. Please include all prescription and NON-prescription medications (i.e. Motrin, vitamins, herbal supplements, Tylenol, etc.)*

EAR, NOSE, AND THROAT HISTORY

Hearing problems/ Ear Fullness / Ear Ringing*

Yes

Mouth breathing*

Yes

Ear infections*

Yes

Snoring/Sleep problems*

Yes

Speech delay*

Yes

Frequent sore throats*

Yes

Dizziness*

Yes

Number of times with strep throat this year:

Cough*

Yes

Swallowing problems*

Yes

Nasal blockage, congestion, or stuffiness*

Yes

Hoarseness*

Yes

Post nasal drip or thick/discolored nasal drainage*

Yes

Tongue tie*

Yes

Nasal bleeding*

Yes

Swollen lymph nodes*

Yes

Sinus pressure, tenderness, or infections*

Yes

Noisy breathing*

Yes

Patient Name:*

Date*

Has your child ever been diagnosed with allergic rhinitis (seasonal allergies)?*

Yes

a. If yes, has he/she ever had skin or blood testing before?*

Yes

b. Has he/she been on allergy shots before?*

Yes

c. What are your child's symptoms? (Select all that apply)*

Runny nose

Stuffy Nose

Sneezing

Itchy nose

Itchy throat

Itchy ears

Itchy/runny/watery/red eyes

Other

N/A

Other:*

d. What triggers your child's symptoms? (Select all that apply)*

Pollens

Grass

Dust

Wind

Fumes

Cats

Vacuuming

Illness

Smoke

Dogs

Mowing

Cold weather

Perfume

Exercising

Cleaning products

Temperature changes

Other

N/A

Other animals:*

Other:

Has your child ever been diagnosed with atopic dermatitis (eczema)?*

Yes

Has your child ever been diagnosed with chronic hives (urticaria) or angioedema?*

Yes

Does your child have a history of recurrent infections? (Select all that apply)*

Yes

Ear infections

Pneumonia

Sinus infections

Skin infections

Bone infections

N/A

Other:

Has your child ever been treated for chronic sinus infection (antibiotics for 4-6 weeks)?*

Yes

Has your child ever had an adverse reaction to foods?*

Yes

a. Which food?*

b. What happened?*

Has your child ever had an adverse reaction to a bee, wasp, hornet, or fire ant?*

Yes

a. When?*

b. What happened?*

Is your child allergic to any medications?*

Yes

a. Medication*

Reaction*

b. Medication

Reaction

BIRTH HISTORY

Pregnancy complications (list any):*

Birth weight:

lbs

How many weeks gestation:*

NICU stay?*

Yes

Newborn hearing screen results were:*

Pass

Fail

Unknown

Patient Name*

PAST MEDICAL HISTORY

Please check if your child suffers from, or has been treated for any of the following medical conditions.

Abnormal development*

Yes

Heart disease/problems*

Yes

Allergies*

Yes

HIV/AIDS*

Yes

Arthritis*

Yes

Immune/autoimmune disorder*

Yes

Asthma*

Yes

Lung Disease*

Yes

Attention deficit disorder*

Yes

Muscle/bone disorder*

Yes

Bleeding tendencies*

Yes

Neurological disorder*

Yes

Cancer*

Yes

Seizures*

Yes

Depression*

Yes

Skin rash*

Yes

Diabetes*

Yes

Thyroid disorder*

Yes

Down syndrome*

Yes

Urinary/kidney disorder*

Yes

Eye Disease*

Yes

Migraine headaches*

Yes

GI disorder/Reflux*

Yes

Other:

PAST SURGICAL HISTORY AND HOSPITALIZATIONS

Please list year and reason for any past surgeries or hospitalizations your child has had:*

Has your child ever been intubated?*

Yes

IMMUNIZATIONS

Up to date?*

Yes

Delayed?*

Yes

SOCIAL HISTORY(check all that apply)

Who has legal custody of the child?*

Both parents

Mother

Father

Other

Other*

Child Lives with:*

Both parents

Mother

Father

Other family

Foster family

Parents are:*

Married

Not Married

Partnered

Separated

Divorced

Does your child attend:*

Daycare

Preschool

Grade in school:

Name:

Number of siblings:

Pets in home?*

Dog

Cat

Other

Other*

Smokers in house, even if they do not smoke inside?*

Yes

Do you have the following in your home? (check all that apply)*

Carpet in Bedroom

Carpet in Living Area

Drapes/Curtains

Visible Mold/Mildew

Window AC Unit

Central AC/Heat

HEPA filters

N/A

FAMILY HISTORY

Please check if any of the following diseases run in your child's family, and indicate which relative(s).

Hypertension

Father

Mother

Brother

Sister

Diabetes

Father

Mother

Brother

Sister

Cancer

Father

Mother

Brother

Sister

Psychiatric Illness

Father

Mother

Brother

Sister

Stroke

Father

Mother

Brother

Sister

Allergies

Father

Mother

Brother

Sister

Asthma

Father

Mother

Brother

Sister

Atopic dermatitis (eczema)

Father

Mother

Brother

Sister

Heart problem

Father

Mother

Brother

Sister

Bleeding tendencies

Father

Mother

Brother

Sister

Other:

Father

Mother

Brother

Sister

PREVIOUS TESTS PERFORMED

Please indicate type of test, date, and where.

Allergy test*

Yes

Type, date, location*

Sweat test*

Yes

Type, date, location*

Hearing test*

Yes

Type, date, location*

Genetic test*

Yes

Type, date, location*

Immune test*

Yes

Type, date, location*

X-ray, CT, MRI*

Yes

Type, date, location*

REVIEW OF SYSTEMS

Please CHECK if your child has had any of the following:

Constitutional

Weight gain/loss

Fatigue

Fever/chills/night sweats

Cardiovascular

Chest pain/tightness

Palpitation

Shortness of breath

Heart attack

Leg pain when walking

Swelling of hands/feet/legs

Musculoskeletal

Joint pain or swelling

Muscle pain/bone pain

Eyes

Blurred vision

Visual changes

Double vision

Corrective lenses

Ears/nose/mouth/throat

Ear pain

Difficulty in hearing

Ringing in ears

Sinus pain

Mouth sore/ulcer

Gum bleeding

Pain on swallowing

Hoarseness

Gastrointestinal

Loss of appetite

Constipation

Bloating/belching

Abdominal pain

Nausea and vomiting

Diarrhea

Change in bowel habits

Blood in stool

Hemorrhoids

Integumentary Skin

Skin color/texture change

Itching

Rashes

Ulcers

Neurologic

Frequent headaches

Numbness

Tremors

Twitching

Breast

Pain

Lump/masses

Nipple discharge

Respiratory

Difficulty breathing

Wheezing

Coughing up blood

Genitourinary

Frequent urination

Pain on urination

Hesitancy

Incontinence

Blood in urine

Impotence

Prostate problem

Menstrual problem

Psychiatric

Anxiety

Feeling depressed

Hematologic/Lymphatic

Easy bruising/bleeding

Bleeding tendencies

Swollen lymph nodes

Endocrine

Thyroid problems

Frequent thirst

Excessive sweating

Heat/cold intolerance

I understand the above information is necessary to provide me with surgical/medical care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any changes to health or medication.

Form completed by(print):*

Relationship to patient:*

Mother

Father

Other

Other*

Parent/Guardian Signature:*

Date*

PHYSICIAN USE ONLY

Reviewed and discussed with patient's guardian.

Attending Physician Signature:

Date

Review of Systems negative except as noted above. Reviewed and discussed with patient's guarding.

Physician Initial/Date:

For Physician Examination and Endoscopy Procedures, as well as Letters to Referring Physician(s), Lab Results, Results, Radiographic Results, and other related office notes, please also see Electronic Medical Record.

Physician Initial/Date:

Privacy Notice

We comply with Federal law, which requires us to maintain the privacy of protected health information, and to provide patients with notice of our legal duties and privacy practices with respect to protected health information.

Please list below those individuals with whom we may share your health care information.

If you have any questions, please speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

I have received a copy of this privacy notice and I both understand and agree to the terms. (Policy can be found in our online forms section).

Parent/Guardian Signature:*

Date*

Parent/Guardian Name (print):*

Referral Acknowledgement

Dear Patient

There are many different kinds of health insurance, each of which has its own set of requirements for referrals. While we are happy to help you understand the details of your policy, it is ultimately a patient’s responsibility to know whether or not they need to have a referral. If you do not have a referral for your visit, your insurance company may not pay for the services billed, and the payment will become your responsibility. Please make sure that you have a proper and up to date referral if your insurance plan requires one.

I acknowledge that I have read and understand this statement above. It is my responsibility to make sure that I have a referral for evaluation and treatment

I accept the Terms of Use *