New Patient form (Pediatric)

Step 1 of 6

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Patient Name*
Date of Birth:*
MM slash DD slash YYYY
Sex:*
- M
- F
Tel #:*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
How did you hear about Penn Medicine Becker ENT & Allergy?*
Date*
MM slash DD slash YYYY
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
- No
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
- No
Mouth breathing*
- Yes
- No
Ear infections*
- Yes
- No
Snoring/Sleep problems*
- Yes
- No
Speech delay*
- Yes
- No
Frequent sore throats*
- Yes
- No
Dizziness*
- Yes
- No
Number of times with strep throat this year:
Cough*
- Yes
- No
Swallowing problems*
- Yes
- No
Nasal blockage, congestion, or stuffiness*
- Yes
- No
Hoarseness*
- Yes
- No
Post nasal drip or thick/discolored nasal drainage*
- Yes
- No
Tongue tie*
- Yes
- No
Nasal bleeding*
- Yes
- No
Swollen lymph nodes*
- Yes
- No
Sinus pressure, tenderness, or infections*
- Yes
- No
Noisy breathing*
- Yes
- No

Patient Name:*
Date*
MM slash DD slash YYYY
Has your child ever been diagnosed with allergic rhinitis (seasonal allergies)?*
- Yes
- No
a. If yes, has he/she ever had skin or blood testing before?*
- Yes
- No
b. Has he/she been on allergy shots before?*
- Yes
- No
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
- No
Has your child ever been diagnosed with chronic hives (urticaria) or angioedema?*
- Yes
- No
Does your child have a history of recurrent infections? (Select all that apply)*
- Yes
- No
*
- 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
- No
Has your child ever had an adverse reaction to foods?*
- Yes
- No
a. Which food?*
b. What happened?*
Has your child ever had an adverse reaction to a bee, wasp, hornet, or fire ant?*
- Yes
- No
a. When?*
b. What happened?*
Is your child allergic to any medications?*
- Yes
- No
a. Medication*
Reaction*
b. Medication
Reaction
BIRTH HISTORY
Pregnancy complications (list any):*
Birth weight:
lbs
How many weeks gestation:*
NICU stay?*
- Yes
- No
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
- No
Heart disease/problems*
- Yes
- No
Allergies*
- Yes
- No
HIV/AIDS*
- Yes
- No
Arthritis*
- Yes
- No
Immune/autoimmune disorder*
- Yes
- No
Asthma*
- Yes
- No
Lung Disease*
- Yes
- No
Attention deficit disorder*
- Yes
- No
Muscle/bone disorder*
- Yes
- No
Bleeding tendencies*
- Yes
- No
Neurological disorder*
- Yes
- No
Cancer*
- Yes
- No
Seizures*
- Yes
- No
Depression*
- Yes
- No
Skin rash*
- Yes
- No
Diabetes*
- Yes
- No
Thyroid disorder*
- Yes
- No
Down syndrome*
- Yes
- No
Urinary/kidney disorder*
- Yes
- No
Eye Disease*
- Yes
- No
Migraine headaches*
- Yes
- No
GI disorder/Reflux*
- Yes
- No
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
- No
IMMUNIZATIONS
Up to date?*
- Yes
- No
Delayed?*
- Yes
- No
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:
Number of siblings:
Pets in home?*
- Dog
- Cat
- Other
Other*
Smokers in house, even if they do not smoke inside?*
- Yes
- No
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
- No
Type, date, location*
Sweat test*
- Yes
- No
Type, date, location*
Hearing test*
- Yes
- No
Type, date, location*
Genetic test*
- Yes
- No
Type, date, location*
Immune test*
- Yes
- No
Type, date, location*
X-ray, CT, MRI*
- Yes
- No
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*
MM slash DD slash YYYY
PHYSICIAN USE ONLY
Reviewed and discussed with patient's guardian.
Attending Physician Signature:
Date
MM slash DD slash YYYY
- 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*
MM slash DD slash YYYY
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 *
Phone
This field is for validation purposes and should be left unchanged.

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Step 1 of 6

HISTORY OF PRESENT ILLNESS

MEDICATIONS:

EAR, NOSE, AND THROAT HISTORY

BIRTH HISTORY

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY AND HOSPITALIZATIONS

IMMUNIZATIONS

SOCIAL HISTORY(check all that apply)

FAMILY HISTORY

PREVIOUS TESTS PERFORMED

REVIEW OF SYSTEMS

PHYSICIAN USE ONLY

Privacy Notice

Referral Acknowledgement