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Sex
• • •
|
General Health Status
• • •
|
|
Patient Weight
|
Patient Height
|
|
Heart Diseases
|
Has the patient ever been diagnosed or treated for the following:
|
|
Heart murmur
|
Irregular heart beat
|
|
Congenital heart defect
|
High blood pressure
|
|
Other heart conditions
|
Explain any conditions (include medications or treatment if appropriate)
|
|
Lung Disease
|
New Subheader
|
|
Asthma
|
Wheezing/Bronchiolitis
|
|
Pneumonia
|
Obstructive sleep apnea
|
|
Other
|
|
|
Other health conditions
|
|
|
Diabetes
|
Kidney Disease
|
|
Seasonal allergies/Eczema
|
GERD/ulcer/hernia
|
|
Recurrent ear infections
|
Seizure disorder
|
|
Psychiatric conditions
|
Genetic syndromes
|
|
Learning disabilities
|
Bleeding disorders
|
|
Muscle disorders
|
Liver disease
|
|
Other
|
|
|
Pregnancy/Neonatal period
|
|
|
Was your child born premature?
|
How many weeks old was your child born?
|
|
Type of Delivery
• • •
|
Explain
|
|
Were there any complications during the newborn period?
|
Explain
|
|
Childhood/Adolescence
|
|
|
Does the patient have any allergies to medications, supplements or latex?
|
Type of reaction
• • •
|
|
Has your child ever been hospitalized?
|
Explain
|
|
Has your child ever had surgery?
|
Explain
|
|
Has your child ever had general anesthesia?
|
Explain
|
|
Has any blood relative had problems with general anesthesia?
|
If so, what kind?
|
|
Is there a history of Malignant Hyperthermia in the family?
|
List all medications and supplements your child is currently taking
|
|
For Adult Patients
|
|
|
Alcohol intake
• • •
|
|
|
Cigarette Smoking
|
Amount/Frequency
|
|
Any recreational drug use?
|
Describe/Explain (including most recent usage)
|
|
For female patients
|
|
|
Are you pregnant or trying to become pregnant?
|
Describe/Explain
|
|
Are you breastfeeding?
|
Describe/Explain
|
|
Last menstrual cycle
|
|
