Plymouth Family Physicians

HEALTH HISTORY NEW PATIENT AGE 13-18

The following will assist us in providing thorough care and in obtaining needed services for your infant or child.

Please complete the form below. Filling out this form electronically will be most efficient. If you prefer to use a Word document please send or bring the electronic file if possible. This form is also available in PDF format if you prefer to print it out and complete it manually.

Name (required)

E-mail

Birth Date

Age

PAST HEALTH HISTORY

List any problems as infant or young child :

List any hospitalizations or surgeries:

Immuniztion history:

CURRENT HEALTH HISTORY

Current medications: (prescription or non-prescription)

Allergies:

Tobacco use
By you? Yes No
By anyone in your home? Yes No

Alcohol use:
By you? Yes No
By anyone in your home that concerns you Yes No

Sodas per week:

Check any problems/questions you have about

Weight gain or loss
Fevers, chills, night sweats
Headaches, head injuries, concussion
Eye problems
Wear contacts or glasses
Dental problems
Braces
Cold or allergy symptoms
Nose bleeds
Ear problems
Hearing loss
Ringing
Ear pain
Thyroid problems
Breast masses
Breast discharge
Breast pain
Breathing problems
Shortness of breath
Asthma
High blood pressure
Chest pain
Palpitations
Heartburn
Ulcers
Constipation
Diarrhea
Bloody black bowel movements
Abdominal pain
Kidney or bladder infection
Pain with urination
Muscle pain
Joint pain or swelling
Broken bones
Sprains
Seizure
Loss of coordination
Rash
Mole change
Skin infections
Hair loss
Depression
Poor sleeping
Appetite problems
Panic attacks
Suicidal thoughts or attempts
Concerns about sexuality or sexual function

Females: Periods started at age:
Problems with your periods:

Family Health History:

Father's name:
Father's health problems:

Mother's name:
Mother's health problems:

Sibling's names:

Sibling's health problems:

Other family members with health problems you feel are important for us to know:

Your current situation:

School you attend:

Who lives at home with you:

Current activities:

ANY OTHER CONCERNS NOT LISTED HERE?

I understand that the information on this page will be sent to Plymouth Family Physicians, S.C. and that this submission is not secure. If you are concerned, don't click the Submit button and PRINT THIS FORM or SAVE IT AS A FILE after completing it. You can then mail it or drop it off at the office. If you choose to complete this form at the office, please arrive at least 30 minutes before your appointment to complete all paperwork.