SECH New Patient Form

New Patient Form - Pediatric

Review of Systems and Past History
Patient's Name:*

First NameLast Name
DOB:*

MonthDayYear
Date
Patient's Current Medications & Dosage:
Name of Medication:Medication & Dosage* Do you need a refill? Yes or No
Name of Medication:Medication & Dosage Do you need a refill? Yes or No
Name of Medication:Medication & Dosage Do you need a refill? Yes or No
Who is the patient's PCP?*

Review of Systems: Please indicate if the patient has had any medical problems, with approx. dates.*

	YES	NO	Comments
Recent fever or weight loss
Eye problems (cataracts, blindness, etc.)
Ear, nose or throat problems
Heart/Blood Pressure Problems/Blood Abnormalities
Respiratory problems (asthma)
Gastrointestinal/Stomach problems (vomiting, pain)
Musculoskeletal Problems (joint or bone)
Skin problems (rashes, acne, etc)
Neurological problems (seizure, headache, stroke)
Thyroid problems, Diabetes
Allergies (Food, Seasonal)/Immunologic
Psychiatric problems (behavior, depression, anxiety)
Sleep (trouble falling or staying asleep, snoring)
Other not listed above (please explain)

Females: Are you pregnant or planning to become pregnant within the next year? Please alert your provider if your answer is yes.
Patient (Parent) Signature*

Clear
Date*

MonthDayYear
Date

Medical Information Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
GENERAL DEVELOPMENT
Complications of pregnancy:
Complications of delivery:
Birth Weight:
Full-term: Yes or premature (weeks gestation):
Vaginal:
C-section:
A. Normal Development (for children ages 3 and older). If normal, skip to PAST MEDICAL HISTORY section
B. For children under age 3, at what age did child...?
1. Gross Motor:
Roll over: Sit unsupported: Type a label Crawl:Type a label
Walk: Type a label Pedal tricycle: Type a label Jump: Type a label
2. Fine Motor:
Pick up raisin with 2 finger grasp: Use spoon: Type a label
Cut with scissors:Type a label
3. Language:
First words other than Mama, Dada:   2 words together:Type a label
Sentences:Type a label  Learn colors:Type a label
Count 1-10:   Type a label
4. Social:
Toilet trained: Type a label
PAST MEDICAL HISTORY

Please describe any past medical problems your child may have had. Where possible, give dates of illnesses/surgeries:
Major illnesses requiring hospitalization:
1.*
2.
3.
Surgeries:
1.*
2.
Other known medical problems not listed above:
1.*
2.
PAST FAMILY MEDICAL HISTORY

Please describe any medical problems that exist or have existed in close family members. List the problem and affected individual(s) if known.
1.*
2.
3.
SOCIAL HISTORY
Who currently resides in your child's home?*
Are there any factors related to custody? Please explain.*
Your child's school and current grade*
If your child attends daycare, how many days/week?
Is there any known history of alcohol, tobacco or drug abuse?*

YesNo
Is there any litigation pending on your child's medical condition?*

YesNo
Signature of responsible party:*

Clear
Date*

MonthDayYear
Date

Generalized Anxiety Disorder 7-item (GAD-7) Scale

Over the last 2 weeks, how often have you been bothered by the following problems? *

	Choose your answer:
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

Total Score =*
(Total your answer scores from above)
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult
Source: Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097.

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
ID #
DATE*

MonthDayYear
Date

Over the last 2 weeks, how often have you been bothered by the following problems? *

	Choose your answer:
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

Total Score =*
(Total your answer scores from above)
Copyright C 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MDC is a trademark of Pfizer Inc.
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult

HEADACHE QUESTIONNAIRE
Name*

First NameLast Name
Date*

MonthDayYear
Date
At what age did you start having any headaches, including “regular headaches”, “sinus headaches”, allergy headaches”?*
For girls/women: at what age did you have your first period?
Do you have headaches more than 15 days a month?*

YESNO
At what age did your headache become more frequent than 15 days a month?
Do you have daily headaches?*

YESNO
At what age did your headache become daily?
How many meals a day do you eat?*

How much do you drink per day approximatively?

	Brand/Type	Ounces
WATER
MILK
JUICE
GATORADE
TEA
COFFEE
SODA

On school/work days, what time do you go to bed?*

Hour Minutes

AM/PM Option
what time do you wake up?*

Hour Minutes

AM/PM Option
On non-school/non-work days: what time do you go to bed?*

Hour Minutes

AM/PM Option
what time do you wake up?*

Hour Minutes

AM/PM Option
Where does your head hurt during a headache?*
What does your pain feel like?*
How long does your headache typically last if untreated?*
Do you ever have a headache when you go to bed at night, and wake up the following day with the headache still present?*

YESNO
how many days in a row did your longest headache last? *
Does your headache ever limit you from being able to go to school/work/events?*

YESNO
how many times a month approximatively does this happen?*
Of the remaining headaches each month (those with which you can still go to school/work/events), how many per month are severe?*
Of the remaining headaches each month (those with which you can still go to school/work/events), how many per month are tolerable and you can remain relatively functional?*
How many days per month do you use pain medications?*

Type a question*

	YES	NO
Worsening of headache by doing routine daily activities (is it better to sit/lay down and relax)?
Worsening of headache when coughing?
Worsening of headache when laughing?
Worsening of headache when lifting heavy objects?
Worsening of headache when straining to have a bowel movement?
Irritability when you have a headache?
Wanting to “shut down” or be left alone to do nothing during your headache?
Better to be in a "not too bright" room when you have a headache?
Better to be in a "not too loud" environment when you have a headache?
Bothered by strong smells when you have a headache?
Better to avoid being in a hot environment (like outside during the summer) when you have a headache?
Painful to touch your head while having a headache?
Prefer not to eat/want to avoid food when you have a headache?
Nausea when you have a headache?
Vomiting when you have a headache?
Abdominal pain when you have a headache?
Diarrhea when you have a headache?
Dizziness when you have a headache?
If dizziness occurs, is it worse upon standing?
Experience fogginess/difficulty concentrating?
Experience complete confusion?
Body collapses or you pass out?
Teary eye on side of headache ONLY?
Droopy eyelid on side of headache ONLY?
Stuffy nose on side of headache ONLY?
Runny nose on side of headache ONLY?
Fullness/pressure in your ear on side of headache ONLY?
Ringing in your ear on side of headache ONLY?
Sweating of your face on side of headache ONLY?
Puffiness of your face on side of headache ONLY?

Do you experience a change in your vision? if yes, please describe.*
Do you experience any other symptoms? If yes, please describe.*
What do you do to help your headache?*

drink plenty of fluidsdrink caffeinesleep/resttake my pain medicinesOther
Things that can bring on your headache?*

stress or anxietyexercisefatiguelack of sleepdehydrationhungerweather changesOther

Did you have any of the following events in your childhood/teenage years?*

	NO	YES	If Yes, at what age(s)?
Colic, as an infant?
As toddler, sudden repeated episodes of neck spasms?
Episodes during which your earlobe suddenly turns red AND painful?
Repeated episodes of sudden vertigo, with no trigger; if yes, from what age to what age?
Repeated episodes of vomiting for no reason; if yes, from what age to what age?
Repeated episodes of abdominal pain for no reason; if yes, from what age to what age?
Repeated episodes of nose bleeds for no reason; if yes, from what age to what age?
Bedwetting beyond the normal age; if yes, until what age?
Teeth clenching or grinding; if yes, from what age to what age?
Growing pains; if yes, from what age to what age?
Motion sickness?

Have you had any of the following procedures?*

	NO	YES	If YES, when?	If YES, where?
CT SCAN
MRI
LP
BLOOD WORK

Does anyone in your family have a history of any of the following:*

	NO	YES	If YES, who?
Migraines
Headaches
Neurological Diseases
Autoimmune Diseases
Kidney Stones
Other

ALTERNATIVE

Acupuncture/AcupressureBiofeedback/NeurofeedbackChiropracticCounseling/CBT/DBTHypnosisMassage/craniosacral/myofascialMeditationPhysical TherapyPilates, Reiki, Yoga
PROCEDURES

Botulinum toxin (Botox, Dysport, Xeomin)Facet BlocksImplanted StimulatorMigraine SurgeryNerve BlocksPain PumpSPG Block (inside the nose)Trigger Point Injection
STIMULATORS

CefalyeNeuraGammaCoreNerivioOther
ANTI-CGRP (Preventive Meds)

erenumab (Aimovig)fremanezumab (Ajovy)galcanezumab (Emgality)eptinezumab (Vyepti)atogepant (Qulipta)
ANTI-MIGRAINE

almotriptan (Axert)dihydroegotamine (DHE-45, migranal, Trudhesa)eletriptan (Relpax)ergometrine, ergonovine (Ergotrate)ergotamine (Cafergot, Ergostat, Ergomar, Bellegral, Wigraine)frovatriptan (Frova)isometheptene (Epidrin, Isocom, Isopap, Migraten, Midrin, Prodrin)lasmiditan (Reyvow)methylergonovine (Methergine)methysergide (Sansert)naratriptan (Amerge)remigepant (Nurtec)rizatriptan (Maxalt)sumatriptan (Alsuma, Imitrex, Migranow, Onzetra, Sumavel, Tosymra, Treximet, Zembrace)ubrogepant (Ubrelvy)zolmitriptan (Zomig)
ANTI-HISTAMINES

brompheniramine (Bromfed, Dimetapp)chlorpheniramine (Aller-Chlor, ChlorHist, Chlorped, Chlorphen, Chlor-Tabs, Chlor Trimeton, Phenalin, Ornade, Triaminic, Wal-Finate)cyproheptadine (Periactin)dexbrompheniramine (Drixoral)dimenhydrinate (Dramamine, Draminate, Gravol)diphenhydramine (Banophen, Benadryl, Diphenhist)hydroxyzine (Atarax, Vistaril)meclizine (Antivert)terfenadine (Seldane)
ANTI-ANXIETY

alprazolam (Xanax, Niravam)buspirone (Buspar)chlordiazepoxide (Librax, Librium)clonazepam (Klonopin)clorazepate (Tranxene)diazepam (Valium)flurazepam (Dalmane)lorazepam (Ativan)midazolam (Versed)prazepam (Centrax)temazepam (Restoril)triazolam (Halcion)
ANTI-NAUSEA

aprepitant (Emend)dronabinol (Marinol)granisetron (Kytril)metoclopramide (Reglan)ondansetron (Zofran)prochlorperazine (Compazine)promethazine (Phenergan)trimethobenzamide (Tigan)thiethylperazine (Torecan)
ANTI-DEPRESSANTS & TRANQUILIZERS

amitriptyline (Elavil, Endep)amitriptyline + perphenazine (Triavil)amitriptyline + chlordiazeloxide (Limbitrol)amoxapine (Asendin)aripiprazole (Abilify)buproprion (Aplenzin, Budeprion, Wellburtin, Zyban)caripazine (Vraylar)chlorpromazine (Thorazine)citalopram (Celexa)clomipramine (Anafranil)desipramine (Pertofran, Normpramin)desvenlafaxine (Pristiq)doxepin (Adapin, Silenor, Sinequan)droperidol (Inapsine)duloxetine (Cymbalta)escitalopram (Lexapro)fluoxetine (Prozac, Symbyax, Sarafem)fluphenazine (Prolixin)fluvoxamine (Luvox)haloperidol (Haldol)imipramine (Tofranil)isocarboxazid (Marplan)levomilnacipran (Fetzima)lithium carbonate (Eskalith, Lithobid)loxapine (Loxitane)maprotiline (Ludiomil)milnacipran (Savella)mirtazapine (Remeron)nefazodone (Serzone)nortriptyline (Pamelor, Aventyl)olanzapine (Zyprexa, Zydis)paroxetine (Paxil)perphenazine (Trilafon)phenelyzine (Nardil)pimavanserine (Nuplazid)promazine (Sparine)protriptyline (Vivactil)quetiapine (Seroquel)rasagiline (Azilect)risperidone (Risperdal)selegiline (Emsam, Zelapar)sertraline (Zoloft)thioridazine (Mellaril)tiothixene (Navane)tranylcypromine (Parnate)trimipramine (Surmontil)venlafaxine (Effexor)vilazodone (Viibryd)vortioxetine (Trintellix)ziprasidone (Geodon)
BLOOD PRESSURE MEDS

acebutolol (Sectral)acetazolamide (Diamox)amlodipine (Norvasc)atenolol (Tenormin)betaxolol (Kerlone)bisoprolol (Zebeta)candesartan (Atacand)captopril (Capoten)carvedilol (Coreg)clonidine (Catapres)cyclandelatediltiazem (Cardizem, Cartia, Tiazac)enalapril (Vasotec)esmolol (Brevibloc)hydralazine (Apresoline)isradipine (DynaCirc)felodipine (Plendil)flunarizine (Sibelium)guanfacine (Intuniv, Tenex)labetalol (Trandate)lisinopril (Zestril, Prinivil)losartan (Cozaar)metoprolol (Lopressor, Toprol)nadolol (Corgard)nebivolol (Bystolic, Systolic)nicardipine (Cardene)nifedipine (Procardia, Adalat)nimodipine (Nimotop)nisoldipine (Sular)penbutolol (Levatol)pindolol (Visken)propranolol (Inderal)sotalol (Betapace)telmisartan (Micardis)timolol (Betimol, Blocadren, Istalol, Timoptic)verapamil (Calan, Isoptin, Verelan)
ANTI-CONVULSANTS

brivaracetam (Briviact)carbamazepine (Tegretol, Carbatrol)eslicarbazepine (Aptiom)felbamate (Felbatol)gabapentin (Neurontin, Gralise, Horizant)lacosamide (Vimpat)lamotrigine (Lamictal)levetiracetam (Keppra)oxcarbazepine (Trileptal, Oxtellar)perampanel (Fycompa)phenobarbitalphenytoin (Dilantin, Phenytek)pregabalin (Lyrica)primidone (Mysoline)tiagabine (Gabitril)topiramate (Topamax, Trokendi, Qudexy)valproate, divalproex sodium (Depacon I.V., Depakene, Depakote)zonisamide (Zonegran)
ANALGESICS

acetaminophen (Acephen, FeverAll, Mapap, Naldecon, Nortemp, Ofirmev, Panadol, Triaminic, Tylenol)aspirin (Alka-Seltzer, Bayer Aspirin, Bufferin, E. C. Prin, Ecotrin, Empirin, Equagesic, Micrainin, St. Joseph)bromfenac (Duract)caffeine containing compounds (Anacin, BC Powder, Excedrin, Goody's Powder, Midol, Vanquish)celecoxib (Celebrex)diclofenac (Arthrotec, Cambia, Cataflam, Flector patch, Voltaren, Zipsor)diflunisal (Dolbid)etodolac (Lodine)fenoprofen (Nalfon)flurbiprofen (Ansaid)ibuprofen (Motrin, Advil, Nuprin)indomethacin (Indocin, Indochron, Tivorbex)ketoprofen (Orudis, Oruvail)ketorolac (Toradol, Sprix)meclofenamate, meclofenamic acid (Meclomen)mefenamic acid (Ponstel)meloxicam (Mobic)nabumetone (Relafen)naproxen (Aleve, Anaprox, Naprelan, Napron, Naprosyn)oxaprozin (Daypro)piroxicam (Feldene)rofecoxib (Vioxx)salsalate (Disalcid, Salflex)sulindac (Clinoril)tolmetin (Tolectin)valdecoxib (Bextra)
SLEEP AIDS

doxylamine (Unisom)eszopiclone (Lunesta)melatoninramelteon (Rozerem)suvorexant (Belsorma)tasimelteon (Hetlioz)trazadone (Desyrel)tryptophan, L-tryptophanvalerianzaleplon (Sonata)zolpidem (Ambien)
MUSCLE RELAXERS

baclofen (Lioresal)carisoprodol (Soma)chlorzoxazone (Lorzone, Parafon Forte)cyclobenzaprine (Amrix, Flexeril)metaxalone (Skelaxin)orphenadrine (Norflex, Norgesic Forte)tizanidine (Zanaflex)methocarbamol (Robaxin)
ANTI-SOMNOLENCE

amantadine (Osmolex, Symmetrel)armodafinil (Nuvigil)modafinil (Provigil)pitolisant (Wakix)sodium oxybate (Xyrem)solriamfetol (Sunosi)
STEROIDS

dexamethasone (Decadron, TaperDex)methylprednisolone (Medrol, Medrol Dosepak)prednisolone (Omnipred, Pediapred, Pred Mild)prednisone (Deltasone, Rayos)
BLOOD THINNERS

acenocoumarolpicotamidewarfarin (Coumadin)
MEMORY MEDS

donepezil (Aricept)galantamine (Razadyne)memantine (Namenda)rivastigamine (Exelon)
OPIATES & RELATED

butalbital (Esgic, Dolgic, Isocet, Fioricet, Fiorinal, Fiorpap, Phrenilin, Zebutal)butorphanol (Stadol)fentanyl (Duragesic, Actiq)codeine (Tylenol #3, Tylenol #4, Fiorinal with codeine)hydrocodone (Hydrocet, Lorcet, Lortab, Norco, Vicodin, Vicoprofen, Zydone)hydromorphone (Dilaudid)meperidine (Demerol)methadone (Dolophine)morphine (Dadian, Ms Contin)oxycodone (Oxy IR, Oxycontin, Percocet, Percodan, Roxicodone, Roxicet, Tylox)pentazocine (Talwin)propoxyphene (Darvon, Darvocet)tramadol containing analgesics (Ultram, Ultracet, Rybix)
OTHER

dextromethorphan (DayQuil, Delsym, Robitussin, Triaminic)guaifenesin (Deconex, Entex, Mucinex, Wal-Tussin)lidocaine nose drops or patches (Lidoderm)mexiletine (Mexitil)magnesiumMigravent (Migralief)oxygenpseudoephedrine (Silfedrine, Sudafed, Sudogest, Suphedrine, Valu-Tapp, Wal-phed)riboflavin (vitamin B2)Other
POTS MEDS

desmopressin (DDAVP)electrolyte fluidfludrocortisone (Florinef)ivabradine (Corlanor)midodrine (Proamatine)salt tablets
ADHD MEDS

amphentamine (Adderall, Adzenys, Dyanavel, Evekeo, Mydayis)atomoxetine (Strattera)dexmethylphenidate (Focalin)dextroamphetamine (Dexedrine, ProCentra, Spansule, Zenzedi)lisdexamfetamine (Vyvanse)
Should be Empty:

New Patient Form - Pediatric

GENERAL DEVELOPMENT

PAST MEDICAL HISTORY

PAST FAMILY MEDICAL HISTORY

SOCIAL HISTORY