Pediatric Neurology SSN#
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1 PATIENT HISTORY QUESTIONNAIRE Pediatric Neurology Physician Initials Date PATIENT INFORMATION PATIENT JHH# DOB# AGE SSN# HOME PH DAY PH CELL PH Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Pediatric Neurology.) Please be sure to include street address and zip code so we can mail reports. Who is your PRIMARY CARE PHYSICIAN? (The doctor who coordinates your care.) Please be sure to include street address and zip code so we can mail reports. We will send copies of your reports to the Referring Physician and Primary Care Physician listed above. Is there anyone else who should receive copies? 1
2 MAIN REASON(s) FOR VISIT Please briefly describe the purpose of this visit. REVISED 1/2008 Physician Notes HISTORY OF PRESENT ILLNESS NOTES What problems are you experiencing? What part(s) of your body does this problem affect? How long have you had this problem? How often does the problem occur? Does the problem occur at a particular time of day? If so, when? How long does the problem last? How severe is the problem? Does anything help make the problem go away? If so, what? Does anything seem to make the problem worse? If so, what? Have you had prior treatment or surgery for this problem? If so: What: By whom: Result: 2
3 CONSTITUTIONAL REVIEW OF SYSTEMS - GENERAL Please check any conditions you have experienced. EARS, NOSE, MOUTH, THROAT CARDIOVASCULAR HEMI-LYMPHATIC Y/N Altered taste/ smell Y/N Balance problem Y/N Angina Y/N Blood disorder Y/N Change in appetite Y/N Dizziness Y/N Chest pain Y/N Diabetes Y/N Weight loss or gain Y/N Ringing in ears Y/N Chest pressure Y/N Endocrine disorder Y/N Unable to sleep Y/N Hearing loss Y/N Fainting Y/N Sickle Cell Disease Y/N Excessive sleepiness Y/N Trouble breathing through nose Y/N Heart Failure Y/N Thyroid Disease Y/N Fatigue Y/N Nose bleeds / discharge Y/N Heart Murmur Y/N Enlarged lymph nodes Y/N Fever Y/N Sinus disease Y/N High blood pressure Y/N HIV exposure Y/N Mouth sores Y/N Low blood pressure Y/N AIDS Y/N Sore throat Y/N Shortness of breath Y/N Trouble swallowing Y/N Leg swelling MUSCULOSKELETAL EYES GASTROINTESTINAL RESPIRATORY Y/N Low back pain Y/N Blurred vision Y/N Abdominal pain Y/N Bronchitis Y/N Neck pain Y/N Double vision Y/N Constipation Y/N Emphysema Y/N Joint pain Y/N Glaucoma Y/N Diarrhea Y/N Pneumonia Y/N Joint swelling Y/N Cataracts Y/N Gastritis Y/N Tuberculosis Y/N Hepatitis Y/N Chronic cough INTEGUMENTARY PSYCHIATRIC Y/N Hiatal Hernia URINARY Y/N Breast disease Y/N Anxiety Y/N Rectal bleeding Y/N Increased frequency Y/N Skin rash Y/N Depression Y/N Ulcer Y/N Incontinence Y/N Trouble concentrating Y/N Vomiting Y/N Sexual dysfunction REVIEW OF SYSTEMS NEUROLOGIC Y/N Confusion Y/N Clumsiness Y/N Choking Y/N Blurred vision Y/N Difficulty Concentrating Y/N Facial numbness / tingling Y/N Difficulty chewing Y/N Decreased hearing Y/N Dizziness Y/N Numbness - arms (L/ R/ B) Y/N Difficulty tasting Y/N Double vision Y/N Hallucinations Y/N Numbness - legs (L/ R/ B) Y/N Drooling Y/N Dysphagia Y/N Headache Y/N Poor balance Y/N Hoarseness Y/N Fainting spells Y/N Lethargy Y/N Poor coordination Y/N Incontinence- bowel Y/N Ringing in the ears Y/N Memory problems Y/N Speech difficulty Y/N Incontinence- bladder Y/N Trouble with smell Y/N Personality change Y/N Stiffness Y/N Nausea Y/N Vertigo/Dizziness Y/N Spells Y/N Trouble walking Y/N Pain Y/N Sexual dysfunction Y/N Weakness - arms (L/ R/ B) Y/N Vomiting Y/N Weakness - legs (L/ R/ B) ALL OTHERS NEGATIVE 3
4 Do you take aspirin or any medicines that contain aspirin? Yes No DRUG ALLERGIES AND REACTIONS Are you allergic to any medications? If so, please list the medication and your reaction to it. MEDICATION REACTION MEDICATION REACTION PAST MEDICAL HISTORY SURGERIES Please list all operations you have had, with approximate dates PROCEDURE DATE SURGEON RESULT Have you ever had a problem with anesthesia? Yes No If so, what substance and what complication? Have you ever had a blood transfusion or received blood products or growth hormone? Yes No If so, when? Why? BIRTH HISTORY What was the patients birth weight lbs ounces Was the patient born prematurely? Were there any problems during delivery? Did the patient have any problems in the newborn period (first month of life)? How long did you child stay in the hospital after birth: If yes, please describe: If yes, please describe: 4
5 DEVELOPMENTAL HISTORY Have you ever had any worries about abnormal or slow development in your child? If yes, please describe at what age you first became concerned, and what symptom(s) made you worry about development: Has your child ever lost developmental skills? Does your child receive any specialized developmental treatment services or special education program (for example, physical therapy or special classroom placement? If yes, please describe: What is your child s current educational placement (school, grade level)? Does your child receive special classroom or classroom modifications? If yes, please list. If you are a returning patient to Neurology Clinic, have you had any illnesses, emergency room visits, hospitalizations, or surgeries since you were last in clinic? Yes No If yes, please explain. SOCIAL HISTORY HOW OLD ARE YOU? HEIGHT: WEIGHT: ARE YOU A TWIN? Y N ARE YOU: LEFT-HANDED RIGHT-HANDED BOTH ARE YOU: SINGLE MARRIED WIDOWED SEPARATED DIVORCED WHAT IS YOUR OCCUPATION? IF MARRIED, WHAT IS YOUR SPOUSE'S OCCUPATION? AGE DO YOU LIVE: WITH PARENTS/SIBLINGS AGE(S) OTHER AGE WHAT IS YOUR HIGHEST LEVEL OF EDUCATION? GRADE SCHOOL HIGH SCHOOL VOCATIONAL SCHOOL COLLEGE GRADUATE SCHOOL 5
6 WHAT ARE YOUR HOBBIES? FAMILY HISTORY Father Mother Father s Parents Mother s Parents Brothers /Sisters Children NOTES Arthritis Bleeding disorder Cancer CNS Tumors Dementia Developmental delay Diabetes Epilepsy Heart Disease Hypertension Kidney Disease Lupus Movement disorders MS Neuromuscular Disease Stroke Thyroid Disease PLEASE TELL US ANYTHING ELSE ABOUT YOURSELF OR YOUR CONDITION THAT YOU THINK WE SHOULD KNOW. FORM COMPLETED BY: RELATIONSHIP TO PATIENT: JHH # 6
7 The Johns Hopkins Hospital 600 North Wolfe Street Baltimore, MD OUTPATIENT MEDICATION LIST Prescriber has made edits to EPR Medication List. Staff needs to make edits to EPR Medication List. This box for hospital use only MEDICATIONS (include over-the-counter and herbal medications) DOSE (e.g., strength, # of pills or drops) ROUTE (e.g., by mouth, inhaled, on skin) FREQUENCY (how often) Example: Vitamin C 500 mg By mouth Once a day Please use additional sheet for more medications. Completed by Reviewing Prescriber Signature /ID number / / Date IF YOU HAVE QUESTIONS ABOUT ANY OF YOUR MEDICATIONS, PLEASE CONTACT THE PERSON WHO PRESCRIBED THEM. Original patient Yellow copy - staff Pink copy - prescriber 7
NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION
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