OSNT: Otolaryngology Specialists of North Texas
Patient Intake Form – Pediatric
PDF Download Pediatric Patient Intake Form 3-24-14
PATIENT INFORMATION
Last Name ________________________ First Name ____________________ M.I. ______ Date of Birth ____/____/______
Age _____ Sex _____ SSN :_____________________Race __________________ Ethnicity ____Hispanic _____Not Hispanic
Address ________________________________ Apt # ______ City ____________________ State _________ Zip ________
Email Address _____________________________________________ Preferred Language __________________________
Home Phone ______________________ Cell Phone ______________________ Work Phone _________________________
How may our office best contact you? (Check one) _____Home Phone _____Cell Phone _____Work Phone
Preferred method of appointment reminder? _____Text _____Email _____Phone (circle: cell or home)
PARENT/GUARANTOR INFORMATION
Name____________________________ Relationship to Patient _______________SSN______________ Date of Birth__________
Address________________________________City/State/Zip______________________Email Address_______________________
Home Phone________________________ Cell Phone_______________________ Work Phone ____________________________
Occupation_________________________________________ Employer________________________________________________
PHARMACY
Pharmacy Name _______________________________________ Phone _______________________ Fax __________________
Address __________________________________________________ City/State/Zip ___________________________________
INSURANCE INFORMATION
Primary Insurance Carrier _____________________________ Secondary Insurance Carrier ___________________________
ID# ______ _________________________________________ ID# _______________________________________________
Group # ____________________________________________ Group # ___________________________________________
Subscriber Name ____________________________________ Subscriber Name ____________________________________
Subscriber SS # ______________________________________ Subscriber SS# ______________________________________
Subscriber Birth Date _________________________________ Subscriber Birth Date ________________________________
Relationship to Patient ________________________________ Relationship to Patient _______________________________
Employer ___________________________________________ Employer __________________________________________
REFERRING PHYSICIAN
Physician Name _______________________________ Practice Phone _____________________________________
May we thank someone else (non-physician) for referring you to our office? __________________________________________
ALLERGY INFORMATION
Drug Allergies _____________________________________Environmental Allergies______________________________________
Are you allergic to latex? _____ Yes _____ No Are you allergic to medical tape? _____ Yes _____ No
SOCIAL HISTORY
Attend day care _____Yes _____No Pets in home _____Yes _____ No Cigarette Smoke exposure _____Yes ______No
Family History of Chronic Ear Infections ______Yes ______No
Patient Name: __________________________________________________________ Date of Birth: ___________________
MEDICATION
Please list all medications you are currently taking including over the counter medications, herbals, etc.
____ No Current Medications
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________
Medication________________________________________________ Reason for Taking _______________________________N
HEALTH HISTORY
What problems are you here for today? __________________________________________________________________________
Do you currently have or frequently experience:
____Allergy Problems ____Birth Defects/Syndrome ____Immune Deficiency ____ Respiratory
____Asthma ____Bleeding Disorders ____Heart Problems ____ Speech/Language Delay
____Anesthesia Problems ____Developmental Disorders ____ Neurological Problems
____Other:_______________________________________________________________________________________________
Birth History Was your child born premature ____Yes ____No Gestational age at delivery ___________________
Complications of Prematurity _______________________________________________________________________________
Prenatal Complications _______________________Current Weight __________Immunizations up to date ____Yes ____No
Did child pass newborn hearing screen ____Yes ____No ____Unsure Any current therapy (PT/OT/Speech)_______________
Have you undergone any of the following surgeries?
Tonsillectomy Date: ____________________ Adenoidectomy Date:______________________
Ear Surgery Date: ____________________ Thyroid Surgery Date:______________________
Ear Tubes Date: ____________________ Nasal/Sinus Surgery Date:______________________
Other______________________________________________________________________________________________________
FAMILY HISTORY
Has anyone in your family had:
____Alcoholism ____Cancer ____Heart Failure ____Mental Illness
____Anemia ____Depression ____Hepatitis ____Reflux
____Arthritis ____Diabetes ____High Blood Pressure ____Sleep Apnea
____Atrial Fibrillation ____Emphysema ____High Cholester0l ____ Stroke
____Asthma ____Epilepsy/Seizures ____HIV/AIDS ____ Thyroid Problem
____Birth Defects ____Glaucoma ____Kidney Disease ____ Tuberculosis
____Bladder Disease ____Headaches ____Liver Problem ____Weight Loss/Gain
____Bleeding Disorder ____Heart Attack ____Lung Problem ____Other:__________________
Other:_____________________________________________________________________________________________________
__________________________________________________________________________________________________________
Patient Name:___________________________________________________________Date of Birth: ____________________
PATIENT REVIEW OF SYSTEMS
Do you frequently have or frequently experience: (Please check ALL that apply)
General ____Healthy ____ Prematurity ____Failure to thrive ____Fatigue
____Fever ____Weight Gain ____Weight Loss
Review of System ____None ____Hyperactivity ____Attention deficit ____Anxiety
____Depression
Allergy/Immunologic ____None ____Reactions ____Itching ____Sneezing
____Eye Irritation ____Immune Problems ____ Other: _____________
Eyes ____None ____Strabismus ____Diminished visual acuity
____Discharge ____Other
Ears, Nose, Throat ____None ____ Bruxism (teeth grind) ____Nose Blocked ____Voice Changes
& Mouth ____Pressure in ear ____ Difficulty Swallowing
____Nosebleed ____Ringing in ears ____Sinus Pain
____Sore Throat ____Other:______________
Endocrine ____None ____Hormone Problems ____Growth Disturbance
____Other:____________________________________
Respiratory (Lungs) ____None ____Cough ____Shortness of Breath while Sitting
____Wheezing ____Shortness of Breath with Exertion
Cardiovascular (Heart) ____None ____Heart Murmur ____Syncope ____Chest Pain
____Cyanosis ____Irregular heart beat ____Other:______________
Gastrointestinal ____None ____GERD ____Constipation ____Diarrhea
____Indigestion ____Nausea ____Vomiting
Hematologic/Lymph Nodes ____None ____Anemia ____Blood disorder ____Bleeding easily
____Easy bruising
Genitourinary ____None ____Urination at Night
____Kidney Problems ____Other:______________
Musculoskeletal ____None ____Fractures ____Bone disease ____Painful Joints
____Weakness
Integumentary ____None ____Dry Skin ____Eczema ____Itchy skin ____Rash
Neurological (Nerves) ____None ____Meningitis ____Head Injury ____Dizziness/Vertigo
____Headache ____Seizures
Psychiatric ____None ____Hyperactivity ____Anxiety ____Depression
____Other:______________
Patient Comments:
Signature of Patient/Guardian __________________________________________________________________