Be sure to visit our Patient Center...
Visit Reliance Family Care
Visit Locust Family Medicine
Meet Our Staff & Ask Questions
Find out what our patients think about us!

Family Medical Links
 
Reliance Family Care
Locust Grove Family
Meet Our Doctors
Meet Our Staff
 
Calendars
Request An Appointment
 
Ask Our Doctors
Ask Our Nurse
Questions & Answers
 
Special Health Assessment
 
Keeping My Family Healthy
Medical Guide
Kid Zone
 
Historical McDonough, GA
Contact & Directions
Patient Testimonials
Join Our Mailing List!


Past Medical History

Locust Grove Family Medicine

  

Please complete the following form and submit for the child(ren) you are registering with our practice.  It will be necessary to complete this form for each child you are registering. If you have questions about this form, please contact our office. Please mark "NA" to all questions that do not apply.  You will not be able to complete the form until this is done.

*Denotes required field
GENERAL PATIENT INFORMATION
Full Name:  *
PATIENT HISTORY
Previous Surgeries: * List month and year, hospital and type of surgery.
Previous Hospitalization: * List month and year, hospital and reason for hospitalization.
Childhood Illnesses and or Problems: * Please check off if your child has ever had:
none croup
mumps/measles T.B./lung disease
chicken pox high blood pressure
eczema/skin problems kidney/bladder problems
pneumonia sexually transmitted disease
asthma/wheezing high cholesterol
cancer handicaps/disabilities
hepatitis diabetes
HIV/AIDS rheumatic fever
hemophilia congenital heart defect
abnormal bleeding heart murmur
allergies convulsions/epilepsy
frequent ear infections emotional disorders or suicide attempts
frequent cold or sore throats    
Please explain any of the above:
Current Medications:  * List name of drug, dose being taken, and how often it is taken. Include any vitamins or fluoride supplements.


  
Drug or Food Allergies: * List and describe reaction.
 
 
BIRTH HISTORY
 
Any significant prenatal complications or conditions noted before this child was born? *
 
Did mother use any cigarettes, alcohol, drugs or other medications during pregnancy? *
If yes, please describe:
 
Delivery:* What type of delivery did the mother have?
 
Prematurity: * Born prior to 37 weeks gestation. 
 
If yes, list gestation at birth:  
Complications at Birth: * List any complications that occurred, such as special resuscitation, meconium at birth, need for oxygen or I.V. fluids, admission for prolonged period of time in the nursery, etc.
Feeding: * Did you breast or bottle feed your child?
 
Any feeding problems during first year of life? * (such as severe refluxing/vomiting of foods or intolerance/allergy to any formulas).  
If yes, please describe:
 
DEVELOPMENTAL HISTORY
Have there been any concerns regarding your child's development? *
If yes, please describe:
Learning Problems: * any history of learning problems?
If yes, please describe:
 
FAMILY HISTORY/SOCIAL HISTORY
Parents Marital Status: *
Mother: *
Age
Occupation
Health Problems
 
Father: *
Age
Occupation
Health Problems
 
 
Age and any health problems of other children NOT being seen in this office?
  
List any other family member on mother (maternal) or father's (paternal) side of the family with a significant medical history.* (such as asthma/allergies, cancer, diabetes, bleeding problems, high blood pressure, history of early heart attacks or need for coronary bypass surgery, sudden death, kidney problems, rheumatologic diseases, or T.B./other lung diseases.)
  
 
IMMUNIZATION HISTORY 
(list month and year when given)
DTaP/DT 1 OPV/IPV 1
DTaP/DT 2 OPV/IPV 2
DTaP/DT 3 OPV/IPV 3
DTaP/DT 4 OPV/IPV 4
DTaP/DT 5 Prevnar1 (PCV-7)
Hib 1 Prevnar2 (PCV-7)
Hib 2 Prevnar3 (PCV-7)
Hib 3 Prevnar4 (PCV-7)
Hib 4 MMR1
Hepatitis B1 MMR2
Hepatitis B2  
Hepatitis B3  
Pneumococcal (Pneumovax)
Td booster
Varicella 1 (Chickenpox)
Varicella 2 (Chickenpox)
Influenza
Other Vaccines
Tine or PPD skin test and result of test.

     
Home | Contact | Patient Lounge  |  Your Privacy  | Top of Page
Dr. Nimisha Trivedi © 2008 | All Rights Reserved