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Instructions: Please complete the from below. You DO NOT have to enter your name or address. This information is optional. If the patient is 13 years old or younger,please complete the Pediatric History in addition to the other information on this form. Thank you.
Patient Entry
Firstname:
Lastname:
*Email:
Gmail.com
*Gender:
Male
Female
*Age:
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> 89
Phone 1:
Phone 2:
Address 1:
Address 2:
City:
State:
Country:
Zip:
*Ethnicity:
NA
Caucasian
frican American
Hispanic
Asian
Other Ethnicity:
Medications:
If you cannot fin your diagnosis or diagnosis in the ICD-9 list then enter the name of your condition(s) in the Daignosis field boxes below the ICD-9 fields.
Diagnosis [ICD9]
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Diagnosis [ICD9]
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Diagnosis [ICD9]
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Diagnosis [ICD9]
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Diagnosis [ICD9]
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Diagnosis[1]
Diagnosis[2]
Diagnosis[3]
Diagnosis[4]
Diagnosis[5]
Diagnosis[6]
Diagnosis[7]
Pediatric History
Family History
157
Birth Defects
NA
Yes
No
Father
Mother
Sibling
Other
158
Genetic Defects
NA
Yes
No
Father
Mother
Sibling
Other
159
Mental Retardation
NA
Yes
No
Father
Mother
Sibling
Other
160
Allergies
NA
Yes
No
Father
Mother
Sibling
Other
161
Lung Disease
NA
Yes
No
Father
Mother
Sibling
Other
162
Asthma
NA
Yes
No
Father
Mother
Sibling
Other
163
Bone/Joint Disorder
NA
Yes
No
Father
Mother
Sibling
Other
164
Rheumatoid Arthritis
NA
Yes
No
Father
Mother
Sibling
Other
165
Muscle Disorders
NA
Yes
No
Father
Mother
Sibling
Other
166
Skin Disease
NA
Yes
No
Father
Mother
Sibling
Other
167
Eye or Ear Disorders
NA
Yes
No
Father
Mother
Sibling
Other
168
Cancer
NA
Yes
No
Father
Mother
Sibling
Other
169
Diabetes
NA
Yes
No
Father
Mother
Sibling
Other
170
Thyroid Disease
NA
Yes
No
Father
Mother
Sibling
Other
171
Heart Disease/Problems
NA
Yes
No
Father
Mother
Sibling
Other
172
Anemia/Blood Disorders
NA
Yes
No
Father
Mother
Sibling
Other
173
High Blood Pressure
NA
Yes
No
Father
Mother
Sibling
Other
174
Kidney Disease/Problems
NA
Yes
No
Father
Mother
Sibling
Other
175
Rheumatic Fever
NA
Yes
No
Father
Mother
Sibling
Other
176
Tuberculosis
NA
Yes
No
Father
Mother
Sibling
Other
177
Seizures/Convulsions
NA
Yes
No
Father
Mother
Sibling
Other
178
MentalDisease/Disorder
NA
Yes
No
Father
Mother
Sibling
Other
179
Venereal Disease
NA
Yes
No
Father
Mother
Sibling
Other
180
HIV/AIDS
NA
Yes
No
Father
Mother
Sibling
Other
785
Other
Disease History
181
Measles (10 day)
NA
Yes
No
182
Rubella (3 day measles)
NA
Yes
No
183
Mumps
NA
Yes
No
184
Chicken Pox
NA
Yes
No
185
Whooping Cough
NA
Yes
No
186
Rheumatic Fever
NA
Yes
No
187
Hepatitis (liver disorders)
NA
Yes
No
188
Bronchitis or Chronic Cough
NA
Yes
No
189
Asthma
NA
Yes
No
190
Pneumonia
NA
Yes
No
191
Anemia/Blood Disorders
NA
Yes
No
192
Difficulty Talking
NA
Yes
No
193
Stuttering
NA
Yes
No
197
Frequent Headaches
NA
Yes
No
782
Other
Eyes
194
Crossed or Wandering
NA
Yes
No
195
Vision Problems
NA
Yes
No
196
Eye Irritation
NA
Yes
No
784
Other
Ears
198
Frequent Ear Infections
NA
Yes
No
199
Hearing Problems
NA
Yes
No
783
Other
Mouth
200
Been to dentist
NA
Yes
No
201
Date of visit
NA
Yes
No
202
Dental Problems
NA
Yes
No
203
Sores in Mouth/Gums
NA
Yes
No
789
Other
Nose and Throat
204
Frequent Sore Throats
NA
Yes
No
205
Persistant Hoarseness
NA
Yes
No
206
Frequent Nose Bleeds
NA
Yes
No
207
Frequent Stuffed Up Nose
NA
Yes
No
208
Frequent Tonsil Infections
NA
Yes
No
792
Other
Heart and Lungs
209
Mouth Breathing
NA
Yes
No
210
Difficulty Breathing
NA
Yes
No
211
Tendency to Wheeze
NA
Yes
No
212
Repeated Coughing Spells
NA
Yes
No
213
Shortness of Breath
NA
Yes
No
214
Propped up in Bed
NA
Yes
No
216
To Squat Down to Breath
NA
Yes
No
788
Other
Nevrous System
218
Dizzy or Fainting Spells
NA
Yes
No
219
Periods of confusion or
NA
Yes
No
220
Disorientation Convulsions, Seizures
NA
Yes
No
222
Tremors (the shakes)
NA
Yes
No
223
Difficulty Walking, Balancing or handling Objects
NA
Yes
No
791
Other
Skin
225
Eczema/Skin Problems
NA
Yes
No
226
Slow Healing Bruises
NA
Yes
No
227
Persistent Rashes
NA
Yes
No
795
Other
Digestive System
228
Frequent Stomach Aches
NA
Yes
No
229
Frequent Diarrhea
NA
Yes
No
230
Frequent Constipation
NA
Yes
No
231
Frequent Nausea or vomiting
NA
Yes
No
232
Worms
NA
Yes
No
233
Bloody or Very Dark Stools
NA
Yes
No
234
Special Food Restrictions
NA
Yes
No
781
Other
Genitourinary System
235
A Urination Problem
NA
Yes
No
236
Painful Burning Urination
NA
Yes
No
237
Blood in Urine
NA
Yes
No
238
Unusual Urine Odor
NA
Yes
No
239
Persistant Diaper Rash
NA
Yes
No
240
Bed Wetting Problems
NA
Yes
No
241
Penis/Vagina Discharge
NA
Yes
No
787
Others
General
242
Excessive Thirst
NA
Yes
No
243
Increase/Decrease Appetite
NA
Yes
No
244
Unusual Heat/Cold Sensitivity
NA
Yes
No
245
Eaten Paint, Dirt, or Plaster
NA
Yes
No
246
Persistantly Tired
NA
Yes
No
247
Unusual Slow Healing Wounds
NA
Yes
No
248
Recurrent Fever
NA
Yes
No
786
Other
Past Six Months
249
Had Frequent Nightmares
NA
Yes
No
250
Been Unusually Nervous or High Strung
NA
Yes
No
251
Had Extreme Mood Swings
NA
Yes
No
252
Been Unusually Disobedient
NA
Yes
No
253
Been Having Problems with Friends
NA
Yes
No
254
Been Having Problems at School
NA
Yes
No
793
Other
Preqnancy History
255
Prenatal Care
NA
Yes
No
256
High Blood Pressure
NA
Yes
No
257
Gestational Diabetes
NA
Yes
No
258
Venereal Disease
NA
Yes
No
259
German (3 Day) Measles
NA
Yes
No
260
Exposure to Known Cause of Birth Defects
NA
Yes
No
261
Any Illness, Infection, or High Fever
NA
Yes
No
794
Other
Past Medical History
Neurological History
538
Brain Injury With LOC
NA
Patient
Family
539
Brain Injury Without LOC
NA
Patient
Family
540
Cerebellum Dysfunction
NA
Patient
Family
541
Cognitive Disorder
NA
Patient
Family
542
CVA
NA
Patient
Family
543
Dementia
NA
Patient
Family
544
Hemiparesis L or R
NA
Patient
Family
545
Hemiplegia Lor R
NA
Patient
Family
546
Migraines
NA
Patient
Family
547
Multiple Sclerosis
NA
Patient
Family
548
Neuropathy
NA
Patient
Family
549
Parkinsons Disease
NA
Patient
Family
550
Seizures
NA
Patient
Family
551
TIAs
NA
Patient
Family
765
Others
Psychiatric History
552
Alcoholism
NA
Patient
Family
553
Anorexia
NA
Patient
Family
554
Anxiety
NA
Patient
Family
555
Anxiety with Panic Disorder
NA
Patient
Family
556
Bulimia
NA
Patient
Family
557
Bipolar Disorder
NA
Patient