Patient name:____________________________________________________________________

PATIENT NAME:____________________________________________________________________

WHAT IS THE MAIN REASON FOR YOUR CHILD’S VISIT TODAY______________________________
HOW LONG HAS THIS PROBLEM EXISTED________________________________________________
PLEASE MAKE A CHECK MARK BY YOUR CONCERNS

EAR PROBLEMS
NOSE PROBLEMS

THROAT/MOUTH/NECK PROBLEMS
____HOARSENESS/VOICE PROBLEMS ____SPEECH DELAY _____________________________________________________________________________________________
MEDICATIONS: Please list name, strength, how often taken.
CURRENT: ___________________________________________________________________________________
PAST 6 MONTHS: _____________________________________________________________________________

ALLERGIES TO MEDICATIONS: List drug name and reaction (rash, swelling, shock)
_____________________________________________________________________________________________

PREVIOUS TEST PREFORMED:


PAST HOSPITALIZATIONS: List reasons and dates of admission.
_____________________________________________________________________________________________
_____________________________________________________________________________________________ 1 | [Clary/Forsen 022012]


SURGERY HISTORY: List procedure, dates, surgeon.
_____________________________________________________________________________________________ ____________________________________________________________________________________
PLEASE CIRCLE NORMAL IF NO PROBLEMS OR PROVIDE DESCRIPTION OF PROBLEM
FEVER, WEIGHT LOSS
NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________ NORMAL OR DESCRIBE: ____________________
FAMILY HISTORY: Circle all that apply for brothers, sisters, parents, grandparents.
Problems with anesthesia
Other medical problems: ________________
SOCIAL HISTORY: Circle all that apply.
Who is legal custody of child? Both Parents, Mom, Dad, Grandparents, Other.
Child lives with: Both Parents, Mom, Dad, Grandparents, Other family/ relatives, Foster family. Parents are: Married, Not married, Separated, Divorced. Does your child attend: Daycare, Preschool, Grade in School? _______ Number of brother/sisters: ________ Pets in home? Dog____ Cat______ Other __________ Smokers in the house, even if they do not smoke inside? 2 | [Clary/Forsen 022012]

Source: http://entforkids-stl.com/wp-content/uploads/2012/03/Clary-Forsen-New-Patient.pdf