Centennial Pediatrics, PC 15464 E. Orchard Rd Centennial, CO 80016 General Information Patient’s Full Name: Nickname: DOB: Male or Female (Circle One) Parent Email Address: Previous Physician/Office: Birth History Length of pregnancy: ______weeks Birth Weight: ______Did Mother have any complications during pregnancy? Yes or No ______Delivery (Circle One): Vaginal or C-Section Reason? ______Was baby ever breech (Circle One): Yes or No Please List: Did baby have any problems after birth? Yes or No ______Current & Past Medical History Please List: Is the patient on any medications? (includes vitamins) Yes or No ______Does the patient have any mental/behavioral issues? Yes or No ______Does the patient have any academic problems? Yes or No ______Does the patient see any specialists? Yes or No ______Does the patient have any allergies (foods, drugs or environmental)? Yes or No ______Are immunizations up to date? Yes or No Any reactions to immunizations? (Circle One): Yes or No ______

Please list hospitalizations, surgeries, serious illness, accidents or blood transfusions. ______Date: ______Date: ______Date: ______Review of Systems (Circle all that apply): General: Easy Bruising Shortness of Breath Day or night time wetting Poor Appetite Unexplained Lump Pneumonia Blood/Protein in Urine Excessive Appetite Acne Wheezing/Asthma Skeletal: Excessive Thirst Eyes: Heart: Leg Pains Under Weight Pain Murmur Swollen Joints Weight Loss Blurred Vision High Blood Pressure Neuromuscular: Too Tall Crossed Eyes High Cholesterol Headaches Too Short Wears Glasses Gastrointestinal: Migraines Difficulty Sleeping Ears-Nose-Throat: Abdominal Pains Weakness Excessive Sleeping Ear Infections Nausea/Vomiting Dizziness Overactive Hearing Loss Diarrhea Staring Spells No Energy Sinusitis Constipation Fainting Memory Loss Frequent Nosebleeds Frequent Indigestion/Reflux Seizures Fevers Mouth Breathing Blood in Stools Breath Holding Confusion Snoring Urinary: Other: Skin: Lungs: Painful Urination ______Rash Chronic Cough Frequent Urination ______

Do you have any concerns about: hearing, vision, speech, Yes or No ______learning problems, behavior problems? (Circle applicable) ______Social History: Patient’s parents are (Circle One): Married, Divorced, Separated, Unmarried, Domestic Partners, Deceased (Mother/Father), Remarried (Mother/Father) If divorced or separated – with whom does patient live and how is time divided? ______Who lives at home with patient? (siblings, extended family, etc.): ______

Father’s occupation: ______Mother’s occupation: ______

Are there smokers in the home? (Circle One): Yes or No

Are there any animals, birds, or reptiles in the home? (Circle and list) Yes or No ______over Patient’s Full Name: ______DOB: ______

Family History: Have any of the patient’s blood relatives had any of the following diseases? If yes, please list the family member. Relationship to Patient Relationship to Patient

Alcohol/drug abuse: Yes or No ______High Blood Pressure: Yes or No ______Allergies: Yes or No ______High Cholesterol: Yes or No ______Anxiety: Yes or No ______Kidney Disease: Yes or No ______Arthritis: Yes or No ______Lupus: Yes or No ______Asthma: Yes or No ______Migraines: Yes or No ______Autoimmune: Yes or No ______Neurologic: Yes or No ______Blood Clots: Yes or No ______Ophthalmology: Yes or No ______Blood Disorders: Yes or No ______Respiratory: Yes or No ______Cancer: Yes or No ______Seizures: Yes or No ______Celiac Disease: Yes or No ______Skin: Yes or No ______Crohn’s Disease: Yes or No ______Stroke: Yes or No ______Depression: Yes or No ______Thyroid: Yes or No ______Diabetes: Yes or No ______Ulcerative Disease: Yes or No ______Eczema: Yes or No ______Other: Yes or No ______Gastrointestinal: Yes or No ______Genetic: Yes or No ______Genitourinary: Yes or No ______Heart Disease: Yes or No ______

Form completed by: ______Relationship: ______Date: ______