Your child has been scheduled for an appointment in Diabetes Clinic of the Children s Hospital University of Illinois
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1 To the Parent/Guardian of: Welcome to the Diabetes Clinic! Your child has been scheduled for an appointment in Diabetes Clinic of the Children s Hospital University of Illinois on: at: with: We have enclosed a medical history form along with information about the Diabetes Clinic. Please fill out the medical history form ahead of time and bring to the clinic appointment and review the enclosed information. If this information applies to you, we ask that you bring your child s blood sugar records and insulin doses for the last 14 days with weekly meal time and bedtime blood sugar averages. If your child uses an insulin pump, please bring the total daily insulin and total daily bolus and basal insulin doses for the last 7 days as recorded in the pump. You will be asked to fill out a 24 hour food history when you arrive. Please arrive 15 minutes before the scheduled appointment time to allow for parking and registration. The Diabetes clinic is inside the Children and Adolescent Center in 2E of the outpatient care center. If you have any questions please call the Diabetes Clinic at (312) or fax (312) We look forward to meeting with you. The Diabetes Team Bienvenidos a la clínica de Diabetes Su hijo/hija tiene una cita en la clínica de diabetes del Hospital de niños de la Universidad de Illinois: Fecha: Hora: Con: Por favor complete el cuestionario adjunto y lo tráigalo el día de su cita. Traiga también un diario con las mediciones de azúcar de su hijo/a y dosis de insulina de por lo menos las últimas 2 semanas. Incluya el promedio del azúcar en sangre a la horas de los alimentos y al acostarse. Si utiliza una bomba de insulina traiga las doses de insulina basales, insulina total por día y total de bolos de insulina por día de los últimos 7 días. Favor de llegar a la clínica 15 minutos antes de su cita. Se puede estacionar en el estacionamiento adjunto al centro de pacientes externos. La clínica de Diabetes se encuentra dentro del Centro para Niños y Adolescentes en el segundo piso sección 2E. Para cualquier duda por favor comuníquese a la división de Endocrinología y Diabetes al Teléfono: o al Fax: Atentamente, El equipo de diabetes 1
2 Endocrine and Diabetes Clinic Patient History Dear Parent, Your child has an appointment in the Endocrine and Diabetes Clinic. We can serve you better if we have his or her full medical history. Please answer these questions before your appointment if possible, and bring the form with you. Use extra paper or write on the back page of the form if needed. Thank you Child s full name: Birthdate: / / Father s full name: Birthdate: / / Mother s full name: Birthdate: / / Parent s marital status: married single divorced widowed Who has legal custody of this child? Shared mother father guardian Home address City State Zip Code Preferred contact telephone number ( ) Your child s primary doctor Phone ( ) Please describe the reason your child was referred to our clinic. MEDICAL HISTORY Pregnancy and birth history. Please respond about the pregnancy with this child. Pregnancy lasted weeks months Did mother smoke during pregnancy? No Yes. Drink alcoholic beverages during pregnancy? No Yes use recreational drugs during pregnancy? No Yes 2
3 Were there any problems during pregnancy or with delivery? No Yes Please describe: Baby s birth weight length Brought baby home after days Breast milk yes no how long? Formula yes no how long? Please describe any problems during the first 2 months of life: DEVELOPMENT How old was your child when he/she could: Sit without help Walk Run Hop Ride tricycle Toilet trained Said first word First 2-3 word sentence First tooth All 20 baby teeth Overall, did this child develop slower, faster, or about the same as other children? School grade: How is your child doing in school? Above average Average Below average Does your child require special education? Last report card grades PUBERTY Has your child started to show pubertal development? Unsure No Yes If yes, how old was your child when you first noticed: growth spurt penis growth Breast growth body odor testicle growth First period underarm hair facial hair Regular periods pubic hair voice change MEDICATIONS (list all medicines, vitamins, and supplements including dose and approximate date started) See medication list Medication name/dose/frequency Start date Medication name/dose/frequency Start Date ALLERGIES (list all allergies and reaction) IMMUNIZATIONS/VACCINES Up to date Not up to date We do not vaccinate Unsure 3
4 SURGERIES/OPERATIONS (list any surgeries your child has had) date surgery performed by- if known where performed HOSPITALIZATIONS (hospital stays not listed above) date reason for hospitalization name of hospital, city, state MEDICAL PROBLEMS (list problems with any of the following including details) Skin problems, spots, or birthmarks Brain, nerves, headaches Vision, hearing, taste, or smell Heart or blood pressure Breathing Weight or height Eating (swallowing, appetite) Stomach or bowels (constipation, diarrhea) Kidneys, bladder, or urination Frequent infections Muscles or bones Weakness or coordination Blood Psychiatric or behavior Sleep (restless, snoring, sleepwalking) 4
5 Activity/energy FAMILY HISTORY Please answer these questions about blood relatives (use back page of form if needed). Please indicate if a parent was adopted. age height/weight age at puberty health problems Birth father first shaved Birth mother first period Birth sibling M/F Birth sibling M/F Birth sibling M/F Birth sibling M/F Birth father s family (paternal side): age height/weight health problems Father s father Father s mother Father s brothers Father s sisters Birth mother s family (maternal side): age height/weight health problems Mother s father Mother s mother Mother s brothers Mother s sisters Other biologic family: Does anyone in the family have problems with anything listed below? Please list which side of the family relative to your child (for example, maternal grandmother). Poor growth Thyroid problems Early or late puberty Diabetes High cholesterol High blood pressure Adrenal hormone problems Kidney problems Heart attack before age 55 Stroke before age 55 5
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Thank you for selecting Darius Peikari, M.D., PA for your healthcare needs. Please fill out the enclosed paperwork and bring it in with you when you come for your appointment. Also, be sure to bring your
Male New Patient Package
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Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone
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Personal Injury Questionnaire
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Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology
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PATIENT REGISTRATION
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Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527
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Women s Continence and Pelvic Health Center
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Referrals It is your responsibility to bring your referral if required. Failure to do so may result in cancellation of your appointment.
Welcome to Capital Endocrinology! We are happy to have you as a patient in our practice. Please take note of the following policies. Following these policies will help in making your visit as efficient
New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.
The Richwood School-Based Health Center is pleased to offer medical, mental health counseling, health education, and on site dental services to all Richwood Middle School and Richwood High School students.
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PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER