Welcome to Our Office
(Pediatrics - 17 & under)
Patient Name
Date of Birth
Did a Physician refer you?
Yes
No
If referred by Physician, Physician name:
If referral is other than a Physician, please indicate:
Friend
Family
Internet
Other
If selected "Other" for referral, indicate here:
List any family members seen by Dr. Ulrich:
General Medical Information
Reason for today's appointment?
How long has this been a problem?
What prior treatment has your child received for this problem?
Height
Weight
Are immunizations up to date?
Yes
No
Does child bruise easily?
Yes
No
Has child ever had cut such that bleeding was difficult to control?
Yes
No
Personal Medical History
Any Heart Problems
Hepatitis
Asthma
Anemia
Bleeding Disorders
Hay Fever
Snoring
Diabetes
Blood Transfusions
Convulsions/Epilepsy
Allergies
Hearing Loss
Restless Sleep
Headaches
Sinus Problems
Other Medical History
Family History
High Blood Pressure
Lung Disease
Cancer
Diabetes
Kidney or Liver Disease
Stroke
Bleeding Disorders
Heart Disease
Hearing Loss
Surgical History
List any previous surgeries and the year the surgery was performed:
Do you have any objection to the use of blood products? (in the unlikely event they should become necessary)
Yes
No
Has your child or any family member had a reaction to any local or general anesthetic?
Yes
No
If "Yes", what type of reaction?
Allergies
Does your child have any allergies to medication?
Yes
No
If medication allergies, please list them here:
Allergic to Latex?
Yes
No
Allergic to X-Ray Dye?
Yes
No
Medications
Does your child take any medications on a regular basis?
Yes
No
Please list all medications your child is currently taking as well as their respective doses:
Parent's Signature (please sign with mouse):
Reset Signature
Today's Date: