TenderCare Pediatrics Docs with a bedside manner you'll appreciate
 
 
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Dr Joseph A. Clan, Jr., MD
Dr Tammy K. Schrodt, MD
Dr James A. Tavelli, MD
Map To TenderCare Peds
New Patient History Form
History Form Part 2
My Health Portfolio
 

D. SOCIAL HISTORY: 

1. Do you live in Louisville?                                                   Yes            No

      If not Louisville, what city/town? __________________

  2. Do other people live in your child's home?                        No              Yes
      Please list names and ages _____________________
  3. Do you have pets?                                                            No              Yes
      Please list type and In or Out ____________________
      What kind? ___________________________­­­­_______                                                      
  4. Do you have city water?                                                  Yes            No
      If not city, please note well or cistern ______________
  5. Does anyone in your home smoke?                                  No             Yes
      Medical literature notes smoking in the home
      predisposes to increased illness.
  6. Does anyone in your home drink alcohol?                         No             Yes
      Medical literature suggests not to use alcohol
      excessively.
  7. Any non-prescription drug use at home?                         No             Yes 
      Medical literature notes increased problems in the home
      with drug use.
  8. Did your child have a previous physician?                        No             Yes
      If yes, please note ____________________________
  9. If transferring from another doctor, can you ask the
     receptionist for a transfer of record form so we may
     have your child's previous records?                                 Yes           No
                                                               
  E. REVIEW OF SYSTEMS:
  1. Has your child had a fever problem?                                 No            Yes
  2. Does your child have a problem with hearing?                  No            Yes                     
  3. Does your child have a problem with vision/eyes?            No            Yes
  4. Has your child had a fatigue problem?                               No            Yes
  5. Has your child had eczema, hives or a skin condition?     No             Yes
  6. Has your child had frequent ear infections?                      No             Yes
  7. Has your child had frequent sore throats?                        No             Yes
  8. Has your child had neck problems?                                   No             Yes
  9. Has your child had wheeze/asthma problems?                 No             Yes
10. Has your child had cough problems?                                 No             Yes
11. Has your child had breast problems?                                No              Yes
12. Has your child had a heart murmur or heart problem?      No              Yes
13. Has your child had diarrhea, constipation or
      abdominal pain problems?                                                 No              Yes
14. Has your child had convulsions or other nervous
      system problem?                                                               No              Yes
15. Has your child had urine or kidney problems?                  No              Yes
16. Has your child had muscle or joint problems?                   No             Yes        
17. Has your child had psychologic problems?                      No              Yes
18. Has your child had an anemia problem?                           No              Yes                        
19. Has your child had an endocrine   problem?                    No              Yes        
20. Has your child had any other medical problems?             No              Yes        
      Please list _________________________________