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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

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February, 2004 Successful Aging Namenda Now Available to Treat Alzheimer’s Disease Namenda (Na-MEN-da) was approved by the FDA on October 17, 2001. It is now justbeginning to be available in local pharmacies. The Memory Clinic in Bennington hasbeen receiving many inquiries regarding Namenda. Here are some of the mostcommonly asked questions. What is Namenda? Namenda is the first medi

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