Patient History Only

After Hour Pediatrics Urgent Care Clinic

PATIENT HISTORY
Select your reason for visit*
Patient Name

First NameLast Name
Patient DOB

MonthDayYear
Date
What is the reason for your visit?

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

YesNo
Have you been exposed to someone who is confirmed to have COVID-19?

YesNo
Onset

HoursDaysWeeks
Number of hours
Number of days
Number of weeks
Severity

MildModerateSevere
Conditions

ConstantIntermittentImprovingWorsening
Better with
What is your condition better with?
Worse with
What is your condition worse with?
If pains:

DullSharpAchyCrampyThropping
If injury,it occurred at

HomeSchoolPublicPrivate Location

Current Medication

	Medication	Time of last dose
1
2

Allergies

YesNo
Medication
Environmental/food
During the day is patient:is primarily at

HomeDay CareWorkSchool
Has patient been exposed to anyone with similar symptoms?

YesNo
Who
Has patient been exposed to Second Hand Smoke?

YesNo
FAMILY HISTORY
What medical conditions run in your immediate family?

NO RELEVANT CONDITIONSAsthmaAllergiesAutismIntestinalEczemaEar infectionsCancerHeadachesCroupNeurologicDiabeticKidney/UTAHeart diseaseFamily history - negative (except as indicated above)Other
OTHER CONCERNS / ROS
Do you have any additional symptoms, problems, or concerns?

YesNO
If Yes: List Symptoms Problems, or concerns?

Head: headache,light-headed,dizzy,seizureEyes: red,itchy,painful discharge,swollenEars/Nose/Throat: pain,congestion,Sneezing,bleedingNeck: stiff,sore,swollen glandsHeart: palpitations,fast heart rateLungs: dry,moist,barky,cough,wheezing,rapid breathAbdomen: vomit,diarrhoea,pain,constipation w/bloodSkin: rash,itchy,burn,cut,dry,hives,eczemas,blistersMuscle/Bones: pain,broken,weak,achy,swollenGenital/Urinary: burning,frequency,urgency,rushFeverOther problems
Head:

headachelight-headeddizzyseizure
Eyes:

reditchypainful dischargeswollen
Ears/Nose/Throat:

paincongestionSneezingbleeding
Neck:

stiffsoreswollen glands
Heart:

palpitationsfast heart rate
Lungs:

drymoistbarkycoughwheezingrapid breath
Abdomen:

vomitdiarrhoeapainconstipation w/blood
Skin:

rashitchyburncutdryhiveseczemasblisters
Muscle/Bones:

painbrokenweakachyswollen
Genital/Urinary:

burningfrequencyurgencyrush
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

MotherFatherGrandparentAdult
Signature

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

YesNO

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

MonthDayYear
Date
Vaccine current?

YesNo
Flu vaccine?

YesNo
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