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Form #1>

Patient's Health History

Form #1

When completing Form #1 (Patient's history form) make every effort to answer all questions. For the majority of question you will be able to choose an appropriate answer from the enclosed choices. When providing descriptive information about the patient use provided spaces and list the information in a chronological order. Pay particular attention when transcribing diagnoses that have been established (or suspected) in the patient and when reporting names and prescribed dosing of medications given to the patient for this illness.

Fields marked with (*) must be filled out.

Code (NN-00000000)*	-
Patient's personal data:
Patient's first name*
Patient's last (family) name*
City of residence*
Street address*
Country of residence*
Patient's birth date*
Patient's place of birth*

Information about the person requesting consult:
First name*
Family name*
City*
Street address*
Country*
Telephone*	-
Fax	-
E-mail*

Details of current illness (the reason for consultation):

When was the FIRST symptom (symptoms) of current illness noticed?

When was the FIRST doctors visit for this symptom (symptoms)?

Please, list ALL diagnoses that have been established or suspected for this illness:

Please, describe patient's symptoms. List symptoms in order of their appearance and be as precise as possible:

List in chronological order names (proprietary or chemical) of all medications that patient has received for this illness. List doses of medications, route and time of their administration, and the duration of treatment for each. Please, elaborate on benefits and side effects of each medication in the patient.

List in chronological order any other therapy that has been given to the patient for this illness. Include: any alternative therapy, physical therapy, speech therapy, massage, psychotherapy, acupuncture, vitamins, and other supplements. .

List in chronological order all hospital admissions for the current illness, dates of admission, name of doctor in charge, doctor's specialty, and all discharge diagnoses:

Hospitalization #1

Hospital

Date of admission

Name of the Doctor

Doctor's specialty

Diagnosis #1

Diagnosis #2

Diagnosis #3

Diagnosis #4

Diagnosis #5

Hospitalization #2

Hospital

Date of admission

Name of the Doctor

Doctor's specialty

Diagnosis #1

Diagnosis #2

Diagnosis #3

Diagnosis #4

Diagnosis #5

Hospitalization #3

Hospital

Date of admission

Name of the Doctor

Doctor's specialty

Diagnosis #1

Diagnosis #2

Diagnosis #3

Diagnosis #4

Diagnosis #5

Hospitalization #4

Hospital

Date of admission

Name of Doctor

Doctor's specialty

Diagnosis #1

Diagnosis #2

Diagnosis #3

Diagnosis #4

Diagnosis #5

What is patient's current height?

What is patient's current weight?

Patient's head circumference (< 3 years):

When was patient's last visit to the doctor for any reason?

Describe reason for this visit:

Please describe in detail patient's current overall condition, current signs and symptoms of the illness patient is experiencing, and (if known) future therapy plans by patient's doctors.

List dates and diagnoses of illnesses other than current disease patient has had in the past:
	1.	2.	3.
Diagnosis
Date
	4.	5.	6.
Diagnosis
Date

List dates and discharge diagnosis for patient's past hospitalizations for other than current illness:
	1.	2.	3.
Diagnosis
Date
Hospital
City
	4.	5.	6.
Diagnosis
Date
Hospital
City

History of mother's pregnancy with this child, birth and early development of the patient:

What was the duration of pregnancy?

Was pregnancy with this patient normal?

YES

Was delivery of this patient normal?

YES

Any problems with patient at birth?

YES

Specify any mother's pregnancy complications with this child by choosing an appropriate answer on the right:

Diabetes or sugar in urine?

Elevated blood pressure

Protein in urine?

Kidney or urinary tract infection?

Venereal diseases including Herpes?

Other infections?

Bleeding during pregnancy?

Specify complications that might have occured during the delivery (birth) of this child?

Cesarean section delivery?

Vacuum assisted delivery?

Placental abruption?

Patient's birth weight

Patient is a

child in this family.

Patient's APGARS scores at birth:

1 min.

5 min.

Specify problems during patients newborn period:

Neonatal jaundice?

Neonatal infection?

Neonatal respiratory problems?

Prolonged hospitalization?

Were there any other problems in newborn period with this patient?Please, describe:

Was this child breast fed?

YES

For how long?

First tooth appeared at...

Patient was sitting independently with...

Patient was walking with...

Patient's present body growth is...

Patient's present development is...

Patient's speech development is...

Has patient received ALL required childhood immunizations?

YES

Has patient received BCG?

YES

Has patient ever had an unusual reaction to any vaccine? Please describe:

Has patient ever exhibited an allergic reaction to medications, foods, pets, or anything else? Please specify:

Family health history:

Age of mother at birth of this child?

Age of father at birth of this child

Mother's current height

Mother's current weight

Father's current height

Father's current weight

Number of persons living with the patient in the same household

Who is the main caretaker of this patient?

Please list all known significant illnesses on both (father's and mother's) sides of the patient's family: