The Chest Wall Center at Cincinnati Children s Patient Questionnaire

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Jade Blankenship
5 years ago
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Today s Date Patient Name First Middle Last Date of Birth Age Home Phone Cell Work Email(s) Address(es) Primary Care Doctor (PCP) PCP S Address Street Address City State Zip PCP S Phone Number Which

1 Today s Date Patient Name First Middle Last Date of Birth Age Home Phone Cell Work (s) Address(es) Primary Care Doctor (PCP) PCP S Address Street Address City State Zip PCP S Phone Number Which surgeon do you prefer to see? Dr. Victor Garcia Dr. Rebeccah Brown No Preference Other: History of Present Illness Did a doctor other than your Primary Care Doctor refer you to us? Yes No If yes, please list below: First Last Referring Doctor s Address Street Address City State Zip

2 Phone Number Are there other Doctors involved in your child s care? Yes No If yes, please list their name(s): Past History Current Medications: Drug/Medication Dose Frequency Pill/Liquid/Etc. Last Dose Allergies: Drug/Medication Nature of Reaction (rash, etc.) Severity Are Immunizations Up to Date? Yes No If no, please list below: Prior Illnesses? Yes No If yes, please state illness, dates, treatments, and duration: Prior Hospitalizations? Yes No If yes, please state dates, reasons and location: Prior Surgery? Yes No If yes, please state type of surgery and date: Prior Injuries? Yes No If yes, please state type of injury, date, and treatment: Allergies to Metal? Yes No Unknown If yes, please list below:

3 Family History: The Chest Wall Center at Cincinnati Children s Patient Food Are both and parents Environmental alive and Allergies? well? Yes Yes No If No no, please Unknown state the deceased If parent yes, please and the list cause below: Prior X-Rays? Yes No If yes, please state type of x-ray and date: of death: How many siblings does the patient have? Brothers Sisters Are they alive and well? Yes No If no, please state illness or cause of death: _ Is there any family medical history related to Pectus? Yes No If yes, please provide details: Has anyone in the family had a reaction to anesthesia (High Fever, Weakness)? Yes No details: Social History: Who lives in the home with the patient? School: Grade: Is the patient active in sports or organized activities? Yes No If yes, please state the type of activity Has the patient had a history of drug/alcohol/tobacco abuse? Yes No If yes, please state the type and duration Do you have any transportation or social concerns? Yes No If yes, please explain What are the patient s hobbies? Any additional social factors you would like us to know? Yes No If yes, please explain Genetic Disorders / Other Conditions or Disorders? Marfans Ehler s Danols Syndrome (EDS) Scoliosis Pectus Hypermobility Connective Tissue Disorder Postural Orthostatic Tachycardia Syndrome (POTS) Diabetes Other:

4 REVIEW OF SYMPTOMS System Respiratory Please check all that apply Cough Chest Pain Wheezing Asthma Pneumonia Recurrent Infection Cyanosis (bluish tint to skin, lips, nails) Shortness of Breath at Rest Heart and Circulations Shortness of Breath with Exercise Chest Pain Murmur Irregular Heartbeat Shortness of Breath Difficulty Breathing Fainting Muscles and Bones Pain Weakness Scoliosis/Spine Joint Pain Curvature of Spine Uneven Shoulders Breast Development (Male/Female) Breast Development started/completed (female) Uneven breasts (female) Abnormal Breast Growth (male) Neurologic Headache Fainting Seizures Dizziness Paralysis Pain Numbness Psychiatric & Emotional Anxiety Depression Nervousness Thoughts of Suicide Emotional instability

5 OTHER If possible, would you like us to try and schedule all of your tests on the same day as your clinic visit (Allergy/Pulmonary Function Test/Scoliosis X-Ray)? Yes No How do you feel your child will handle and recover from Surgery? How did you hear about us? Website Referred Facebook Pectus.com (Pectus Awareness and Support Foundation) Other: INSURANCE *IT IS IMPORTANT YOU SEND YOUR CURRENT INSURANCE CARD WITH THIS FORM ALONG WITH THE POLICY HOLDER S NAME AND DATE OF BIRTH* Policy Holder Name First Middle Last Policy Holder Date of Birth

6 The above information is true and accurate to my knowledge. Parent/Guardian Signature and Date Initials/Date Initials/Date Initials/Date Parent/Guardian Signature and Date Initials/Date Initials/Date Initials/Date Provider Signature and Date Initials/Date Initials/Date Initials/Date

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