Individual ‘MINOR’ – History And Physical Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.It is extremely helpful to have you prepare some information before your first appointment. This ensures that our visit is as thorough and useful as possible. These forms include a questionnaire, diet diary, disclosures and consent form. Please complete all pages of the questionnaire. You can fill out the diet diary for any 3 days in a row between now and your appointment. Thank you for putting your time into this preparation and please remember to bring them with you to your appointment. LayoutChild's Full Name *Child's Age *Parent's or Guardian's Full Name *Parent's or Guardian's Email Address (copy) *Date of BirthGender at Birth *MaleFemaleDo not want to discloseSchool Name & (ISD)Parent's or Guardian's Phone Number *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeReason for Visit *Past Medical HistoryChronic Illnesses *Surgeries *Medications, Hormones and/or Supplements (including dosage) *Allergies *Reproductive System (Girls only) *Family HistoryIndicate any ailments which have affected your relatives. Do/did they have the same ailments as you? Possible ailments: AIDS, alcoholism, allergies, arthritis, asthma, cancer, diabetes, drug addiction, epilepsy, frequent colds, gonorrhea, gout, heart problems, mental illness, neurological problems obesity, pleurisy, pneumonia, skin problems, syphilis, thyroid problems, tuberculosis, ulcers, warts.Mother (Age & Ailment) *Father (Age & Ailment) *Siblings (Age & Ailment)Paternal Grandfather (Age & Ailment)Paternal Grandmother (Age & Ailment)Paternal Uncle/Aunt (Age & Ailment)Maternal Grandfather (Age & Ailment)Maternal Grandmother (Age & Ailment)Maternal Uncle/Aunt (Age & Ailment)Social HistoryLayoutActivity Level *Diet *Any Additional Behavioral TraitSocial Behavior *Exercise *Review of Systems (ROS)Patients are often asked to check any symptoms they currently have or have had in the last 6-12 months. LayoutRespiratory *Shortness of BreathCoughWheezingChest TightnessHemoptysis (coughing up blood)Neurological *HeadachesDizzinessSeizuresNumbness or tinglingMemory loss or confusionEndocrine *Excessive thirstExcessive hungerHeat or cold intoleranceWeight gain or lossFatigueGenitourinary *Painful urinationFrequent urinationBlood in urineMenstrual irregularities (for females)Musculoskeletal *Joint painMuscle painBack painSwelling in jointsLimited range of motionDermatological *RashesItchingDry or oily skinAcne or skin eruptionsMoles with changes in size, shape, or colorPsychiatric *DepressionAnxietyMood swingsHallucinations or delusionsSleep disturbancesCardiovascular *Chest PainPalpitationsShortness of breathLeg swelling or edemaHistory of fainting or syncopeSubmit
