Mother/Guardian S Name: Ph

Patient Name: MR#

Mother/Guardian’s Name: Ph #:

PMD: Ph #:

HPI: This is the – hospitalization of this -- D/M/Y/O Hispanic/ African/Asian M/F. Chronological description of the illness

Sick Contact: History of Traveling:

Past History: Hospitalizations: Surgery:

Current Medications: (Since when)

Allergy to Medications or food: Type of reaction: describe the event

Pre natal History Natal History: Mother’s age: G: P: A: Hospital: Lincoln, other Pregnancy problems: HTA, DM, other Weeks of gestations: Infection: GBS, Chlamydia, other NSVD/CS/Vacuum FT/PT AGA/LGA/SGA Admissions: Birth Weight: Drugs/Alcohol/Smoke: Apgar: Complications: Any problem at birth: jaundice, respiratory distress, etc Neonatal Screening: result Breastfeeding: for how long

Post Natal Hx: Immunizations: Home environment: Card reviewed: Y N Apartment or house: Where: Family History: How many people live with pt: (who and age) Smoking/Pets: Asthma hx: Asthma symptoms since: Education/Employment: Frequency of exacerbations: Last grade finished: # of Hospital admission due to asthma: Grades: # of PICU admissions: School problems: # of Intubations: Work/employment: # of ER visits: Date last Hospital admission: Date last ER visit: Activities: Triggers: Asthma Risk Factors: Drug use: (family hx of asthma, hx of Suicidal Ideation: eczema, allergies, eosinophilia, smoke Substance use: exposure, hx of severe Sexual Hx: RSV infections) Currently sexually active: Age of first sexual relation: Day time symptoms: How many partners in the last year: (cough, wheezing, SOB Male, female or both: frequency days/months) Use condoms: Any other contraception: Night Time symptoms: (cough, wheezing Hx of STD: frequency days/months, exercise tolerance, sleep Diet/Nutrition: disturbances) Formula: ounces and frequency Foods: Menstrual Hx: Vegetarian: Menarche: Regular: Regular cycle: Frequency: Annual Screening: LMP: PPD: date and result Lead: Developmental: CBC: Describe according to age

Review Of Systems: ___Orthopnea: ___Cough: ___Poor stream: General: ___Palpitations: ___Exertional ___U retention: Psychiatry: Growth and ___Post-nocturnal dyspnea: ___Incontinence: ___Anxiety: development: ___Dyspnea: ___Dyspnea: ___Hx of UTI: ___Depression: ___Healthy: ___Syncope: ___Freq inhaler use: ___Enuresis: ___Difficulty sleeping: ___Loss of appetite: ___Hemoptysis: ___Edema: ___Hyperactive: ___Insomnia: ENT: ___Murmur: ___Flank pain: ___Nervousness: ___Lipodistrophy: ___Dec hearing: ___Palpitations: ___Sphincter control: ___Fever: ___Tinnitus: ___Wheezing: Endocrine: ___Fatigue: ___Vertigo: Musculoskeletal: ___Changes in ___Night Sweat: ___Sinus/ear/tonsillitis/ Gastrointestinal: ___Joint hair/nails: ___Weight Loss: pharyngitis: ___Frequency of BM pain/stiff/swelling: ___Heat or cold ___Weight gain: ___Sneezing: ___Abdominal pain ___Muscle intolerance: ___Nasal discharge: ___Abnormal stools pain/stiffness: ___Polyuria: Ophthalmology: ___Nasal obstruction: ___Nausea: ___Polydypsia: ___Eye swelling: ___Nasal bleeding: ___Vomiting: Integumentary: ___Red eye: ___Altered smell: ___Diarrhea: ___Bruises: Hema/Lymphatic: ___Itchy eye: ___Snoring: ___GI bleeding: ___Itching: ___Tender or draining ___Eye pain: ___Mouth breathing: ___Lesions: nodes: ___Visual ___Sleep apnea: Genitourinary: ___Pruritus: ___Enlarged lymph disturbances: ___Hoarseness: ___Urine: ___Rashes: nodes: ___Blurry vision: ___Cough: ___Dysuria: ___Ulcers: ___Easy bruisability: ___Diplopia: ___Neck mass/pain: ___Polyuria: ___Pallor: ___Thyroid mass: ___Oliguria: Neurologic: Cardiovascular ___Enlarged glands: ___Nocturia: ___Headache; Allergy/Immunology: ___Chest pain: ___Hematuria: ___Apnea: ___Hives; ___HTN: Respiratory: ___Frequency: ___Snoring: ___Seasonal rhinitis: ___Leg pain: ___Hx of pneumonia: ___Urgency: ___Diplopia: ___Sensitive to ___Lower leg swelling: ___Hx of asthma: ___Hesitancy: ___Sensory or motor allergens: ___Murmur: ___Chest tightness: ___Dribbling: deficits: Bastos/Sia