Form 090372 PDF Details

The 090372 form is a crucial document for pediatric patients visiting the University of Virginia Health System's Department of Neurological Surgery. Designed to gather comprehensive medical history, this form plays a vital role in ensuring that healthcare providers have all the necessary information to offer the best care. Upon scheduling an appointment, patients are instructed to bring the completed form alongside their medications and any previous medical records or X-rays. This facilitates a thorough review of the patient's health background, including the history of present illness, medical conditions, previous hospitalizations or surgeries, developmental history, and current medications or known drug allergies. It also includes sections for family and social history, a review of systems to check for symptoms across different bodily functions, and details about the patient's educational background and living situation. By providing detailed instructions for completion and emphasizing the importance of accuracy, the 090372 form ensures that healthcare providers can make informed decisions tailored to the unique needs of pediatric patients.

QuestionAnswer
Form NameForm 090372
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names090372 uic neurosurgery form

Form Preview Example

UNIVERSITY OF VIRGINIA HEALTH SYSTEM

PLACE LABEL HERE.

0300004

IF LABEL NOT AVAILABLE, WRITE IN PT NAME & MR#

DEPARTMENT OF NEUROLOGICAL SURGERY MEDICAL HISTORY FORM – PEDIATRIC PATIENTS

PLEASE BRING COMPLETED FORM WITH YOU TO YOUR SCHEDULED APPOINTMENT AS WELL AS ALL YOUR MEDICATIONS AND ANY PRIOR MEDICAL RECORDS OR X-RAYS

Please assist in obtaining the most accurate information regarding your medical history by completing the information below. If you have already completed this form for our department, please disregard. Your assistance is greatly appreciated.

GENERAL INFORMATION:Date: _____________________________

Name ________________________________________________________________________________________________________

LASTFIRSTMIDDLE INITIAL

Home Address _________________________________________________________________________________________________

_________________________________________________________________________________________________

 

(CITY)

(STATE)

 

 

(ZIP CODE)

Home Phone (

)

 

Work Phone (

)

 

 

Date of Birth:____________ Gender (check one): oMale oFemale Are you: oLeft-handed

oRight-handed oAmbidextrous

1.Please give the name, address, and phone # of your pediatrician / family Dr. and any referring Dr.’s you would like information sent to: _____________________________________________________________________________________________________

____________________________________________________________________________________________________________

2.What is the main reason for your visit today? _____________________________________________________________________

3. Did you bring medical records, slides, and/or x-rays with you today? o Yes o No

HISTORY OF PRESENT ILLNESS: Please describe the symptoms of your medical problem.

Location and Severity of Problem: _________________________________________________________________________________

How long have you had the symptoms? _______________________ When do you have the symptoms? _______________________

What makes the symptoms better or worse? ________________________________________________________________________

MEDICAL HISTORY:

1. Term Birth? Yes____ No____ If not, birth at _____ weeks gestation. Method of delivery: Vaginal _____ C-Section _____

2. List any medical conditions you have:

MEDICAL CONDITIONS

Condition

When Diagnosed?

Condition Currently Under Treatment

3. Have you ever been hospitalized or had surgery? o No o Yes If yes, please list all previous surgeries and hospitalizations below (include dates and hospitals when possible).

HOSPITALIZATIONS

Date of Hospitalization

Type of Surgery

Reason for Surgery

4.DEVELOPMENTAL HISTORY: (circle all that apply)

Able to hold head up

Able to sit up unassisted

Able to follow object with eyes

Able to crawl

Able to grasp toy

Able to feed self

5.ARE YOU CURRENTLY UNDERGOING:

Physical Therapy o No o Yes

Occupational Therapy

Able to imitate speech/sounds

Able to speak in sentences

Able to walk

 

Able to use fork and spoon

Able to speak simple words

Able to dress self

 

 

Able to broad jump

o No o Yes

Speech Therapy o No o Yes

FORM # 090372

CAT: 03 - HEALTH HISTORY

(ORIG. 03/09)

To reorder, log onto http://www.virginia.edu/uvaprint

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6. Do you take any medications? o No o Yes If yes, please list below:

CURRENT MEDICATIONS

Name/Dose/Route of Medication

Date Started Medication

How Often Is It Taken?

Reason for Taking Medication

7. Do you have any known drug allergies? o No o Yes If yes, please list them below:

KNOWN ALLERGIES

Name of Medication

Reaction to Medication

FAMILY HISTORY: (Please list any illnesses that run in your family, including heart disease, diabetes, seizures, or cancer)

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

SOCIAL HISTORY: (Please circle the correct answer)

 

 

 

•฀฀ Education:

PRESCHOOL

GRADE SCHOOL

MIDDLE SCHOOL

HIGH SCHOOL

COLLEGE

Who฀do฀you฀live฀with? ___________________________________________________________________________________________

REVIEW OF SYSTEMS: (Please check all that describe your symptoms)

Constitutional

o Nausea/Vomiting

o Dry skin

o Facial weakness

o Fever

o Abdominal Pain

o Loss or gain of body hair

o Decreased sense of smell

o Night sweats

o Incontinence / Constipa-

o Anxiety

or taste

o Weight loss

tion / Diarrhea

o Weight loss or gain

o Difficulty swallowing

Cardiovascular

Genito-Urinary

o Excessive thirst

o Slurred speech

o Shortness of breath

o Burning with Urination

Hematologic

o Headache

o Chest pain

o Difficulty starting / ending

o Easy bruising

o Dizziness

o Irregular heart beat

urine stream

o Nose bleeds

o Seizures

Respiratory

o Poor bladder control of

o History of excessive bleed-

Musculoskeletal

o Chronic cough / Cough-

incontinence

ing with previous surgeries

o Neck pain

ing blood

o Loss of sensation of geni-

Neurological

o Arm pain / numbness /

o Bronchitis

tals

o Change in vision (blurry,

weakness

o Asthma

o Inability to obtain, maintain

double)

o Loss of arm / hand coordi-

Gastro-Intestinal

erection

o Loss of hearing or ringing

nation

o Blood in stool/Dark col-

Endocrine

in ears

o Back pain

ored stool

o Nipple discharge

o Facial numbness

o Leg pain / numbness

 

 

 

 

Completed by: _________________________________________________________________________________________________

Patient / Parent / Guardian Signature

Reviewed by: _____________________________________________ PIC # ________ Title _______________ Date_______________

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