Patient History Only

After Hour Pediatrics Urgent Care Clinic

PATIENT HISTORY
Select your reason for visit *
Patient Name

First Name Last Name
Patient DOB

Month Day Year
Date
What is the reason for your visit?

COVID-19 Test Other Reason: list below
Do you have COVID-19 Symptoms?

Yes No
Have you been exposed to someone who is confirmed to have COVID-19?

Yes No
Onset

Hours Days Weeks
Number of hours
Number of days
Number of weeks
Severity

Mild Moderate Severe
Conditions

Constant Intermittent Improving Worsening
Better with
What is your condition better with?
Worse with
What is your condition worse with?
If pains:

Dull Sharp Achy Crampy Thropping
If injury,it occurred at

Home School Public Private Location

Current Medication

	Medication	Time of last dose
1
2

Allergies

Yes No
Medication
Environmental/food
During the day is patient:is primarily at

Home Day Care Work School
Has patient been exposed to anyone with similar symptoms?

Yes No
Who
Has patient been exposed to Second Hand Smoke?

Yes No
FAMILY HISTORY
What medical conditions run in your immediate family?

NO RELEVANT CONDITIONS Asthma Allergies Autism Intestinal Eczema Ear infections Cancer Headaches Croup Neurologic Diabetic Kidney/UTA Heart disease Family history - negative (except as indicated above) Other
OTHER CONCERNS / ROS
Do you have any additional symptoms, problems, or concerns?

Yes NO
If Yes: List Symptoms Problems, or concerns?

Head: headache,light-headed,dizzy,seizure Eyes: red,itchy,painful discharge,swollen Ears/Nose/Throat: pain,congestion,Sneezing,bleeding Neck: stiff,sore,swollen glands Heart: palpitations,fast heart rate Lungs: dry,moist,barky,cough,wheezing,rapid breath Abdomen: vomit,diarrhoea,pain,constipation w/blood Skin: rash,itchy,burn,cut,dry,hives,eczemas,blisters Muscle/Bones: pain,broken,weak,achy,swollen Genital/Urinary: burning,frequency,urgency,rush Fever Other problems
Head:

headache light-headed dizzy seizure
Eyes:

red itchy painful discharge swollen
Ears/Nose/Throat:

pain congestion Sneezing bleeding
Neck:

stiff sore swollen glands
Heart:

palpitations fast heart rate
Lungs:

dry moist barky cough wheezing rapid breath
Abdomen:

vomit diarrhoea pain constipation w/blood
Skin:

rash itchy burn cut dry hives eczemas blisters
Muscle/Bones:

pain broken weak achy swollen
Genital/Urinary:

burning frequency urgency rush
If fever, how high?
CONSENT / FOLLOW UP INFORMATION
For follow-up,such as lab results,X-ray reports,or billing matters,I prefer AHP to notify me by phone or email at:

If AHP cannot reach me by phone, I authorize AHP to leave a detailed message about the care of the patient.
I certify that the above information is true and I consent to any medical or surgical treatment rendered to the patient under the general or special instructions of the physician.
I understand I may review in detail AHP's Privacy Practices. I am aware of my right to request special privacy considerations.
Signature of

Mother Father Grandparent Adult
Signature

Clear
Do you have any past, recurring, or chronic conditions relevant to your visit?

Yes NO

Birth History: Wgt. Problems .
Date of last physical/well care visit

Month Day Year
Date
Vaccine current?

Yes No
Flu vaccine?

Yes No
Should be Empty:

	Select	Comment
Hospitalization
Operations
Neuro/Behavioral
Autism
Developmental
Emotional
Eyes/Ears/Throat
Breathing/Lungs
Heart
Abdomen
Urine/Kidney
Genital/STD/LMP
Skin
Other

After Hour Pediatrics Urgent Care Clinic