Health History for New Patient: Age 13 – 18 Years Name* First Last Email of person submitting this form* Date of Birth AgeSelect one131415161718List any problems as an infant or young childList any hospital stays or surgeriesImmunization historyCurrent medications and supplements (prescription and over the counter)Allergies / reactions to medicationsTobacco use by you? (Teen)YesNoTobacco use by anyone in your home?YesNoAlcohol use by you? (Teen)YesNoAlcohol use by anyone in your home that concerns you?YesNoSodas per weekCheck any problems or questions you have regarding:General Weight gain or loss Fevers, chills, night sweats Headaches, head injuries, concussion Eyes Eye problems Do you wear contacts or glasses? Yes No Mouth Dental problems Braces Cold or allergy symptoms Nose bleeds Ears Ear problems Hearing loss Ringing Ear pain Thyroid problems Breast Masses Discharge Pain Lungs Breathing problems Shortness of breath Asthma Heart High blood pressure Chest pain Palpitations Digestive Heartburn Ulcers Constipation Diarrhea Bloody bowel movements Black bowel movements Abdominal Pain Urinary Kidney or bladder infection Pain with urination Muscle / Bone Muscle pain Joint pain Joint swelling Broken bones Sprains Brain / Spine Seizure Loss of coordination Skin Rash Mole change Skin infections Hair loss Behavior / Mental Health Depression Poor sleeping Appetite problems Panic attacks Suicidal thoughts or attempts Sexuality General concerns Sexual function Females - Period started at age:9101112131415161718Females - Problems with your periodsFamily Health History(Please list all that apply)Father's NameFather's health problems:Mother's NameMother's health problems:Sibling's Name(s)Sibling's health problems:Please list any other family health problems that you feel are important for us to know:School you attend:Who lives at home with youCurrent activitiesAny other concerns not listed here?Please review your answers before submitting. Thank you!