(Name) JFHPHealth Questionnaire (Ages 13 18) (Date)
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- Derrick Doyle
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1 (Name) 13 1 (Reg.#) UMHS JFHP (Age) (M) (F) JFHPHealth Questionnaire (Ages 13 18) (Date) 1-2 Please answer the following health questions for your child. It will take you approximately minutes to complete this form, so please complete it at home. Please attach your child s immunization records. Do you have any current health concerns for your child? Please explain. How long in the US? Yr(s) Mo(s) How long do you plan on staying in the US? Yr(s) Mo(s) permanent resident Is your child feeling adjusted to life in the US? Yes Yes Have you ever lived in a foreign country? - what countries, when? Family Members Name Relation to child Age Occupation Is everyone living together? Yes 1
2 Personal/Family History Please mark the following conditions that apply to your child and explain. Hay Fever, Pollen allergy Asthma self sib s mom dad PGP MGP please explain Behavior Problems Blood problems (Anemia, leukemia, hemophilia) Blood clots/phlebitis Arthritis/Joint Disease Cancer Mental trouble/depression Sugar diabetes Alcoholism or Substance Abuse Emotional Abuse Physical Abuse Sexual Abuse Stomach, bowel, etc. Vision problem Hearing loss Heart disease Heart murmur 2
3 Stroke High blood pressure self sib s mom dad PGP MGP please explain Low blood pressure High cholesterol Kidney, Bladder infection Lung Disease Liver disease, Jaundice, Hepatitis Thyroid gland trouble Seizures, Fits, Epilepsy Migraine headaches Rheumatic fever Tuberculosis STD s Motor vehicle accident Serious injury OthersSpecify Please list any operations, surgical procedures, blood transfusions, and hospitalizations. 3
4 Medication Please list all current medications. Are you using any herbal treatments or vitamin supplements? Please explain Yes Allergies Are you allergic to any medications? Yes If yes, please specify drug(s) type of reaction Food allergies? Yes If yes, please specify food(s) type of reaction Immunization Please attach a copy of your child s immunization record. Health Habits Nutrition Meals 1times/day Snacks times/day Yes Sufficient intake of protein, vegetables, and fruit? If no, please explain Caffeinated drinks per day? 4
5 cups/glasses per day Elimination Yes Does your child have any problem with elimination? If yes, please explain Sleeping o clock to o clock Safety: Do you wear a seatbelt or use a car seat? Yes Do you wear a helmet for bike riding/rollerblading? Yes Do you have smoke detectors installed at home? Do you have carbon monoxide detectors installed at home? Do you have fire extinguishers at home? Yes Yes Yes Do you have a fire escape plan? Yes Does your child know emergency phone numbers? Yes Do you keep all medicines, vitamins, cleaning fluids, and gardening chemicals locked away or disposed of safely? Yes 5
6 Poison Control Is the phone number for the Poison Control Center listed near all phones? Yes Dental Screening : Which type of water does your child drink? tap water well water bottled water Your child may need fluoride if he is not drinking tap water or if your water supply does not have fluoride added to it. How often do you brush your child s teeth? times/day How often do you have a dental check-up? times/year 2 We recommend a dental check-up twice a year. other 1 ( )hrs How many hours does your child watch TV or use a computer per day? 11-2 Limit TV and electronic game time to a total of 1-2 hrs per day. Carefully select the TV programs that you allow your child to view. Be sure to watch some of the programs with your child and discuss the show. Avoid watching any programs that contains violence. Do not put a TV in your child s bedroom. What kind of sports does your child participate in or have interest in? Yes, who Does anyone in your household smoke? Yes 6
7 Any concerns about your child s growth and development? If yes, please explain Any problems with school? Yes If yes, please explain. Please write down your child s daily routine. 12am 6am 12pm 6pm Does your child currently have any of the following symptoms? Please circle all that apply. JFHP 9/04 General Review of Systems fever decrease in activity level loss of appetite Head Eye headache injury visual change cross-eyed discharge redness puffiness Ear difficulty hearing pain discharge se Mouth/throat runny nose nasal congestion nose bleed sore throat dental defect difficulty swallowing Lung Heart shortness of breath coughing chest pain wheezing pale cyanosis chest pain swelling on legs faint 7
8 Gastrointestinal Genitourinary Musculoskeletal Neurologic Skin Psychiatric abdominal pain nausea vomiting diarrhea constipation distention blood in stool painful urination blood in urine bed-wetting vaginal discharge deformities joint pain joint swelling difficulty in moving extremities or in walking dizziness weakness hand shakiness seizures rash itching color change easy bruising/bleeding freq. mood change nervousness tension feeling down insomniat 8
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