New Patient Form | Tampa Children's ENT

Patient Medical History

Has the child had any recent imaging related to reason for visit? *

Yes

Birth History:

How many weeks was your child at birth? *

Where was your child born? *

Please list any complications with pregnancy or delivery: *

Did your child stay in the NICU? *

Yes

If yes, how long was the NICU stay? *

Did your child pass the newborn hearing screening? *

Yes

If no, which ear(s)?

Right

Left

Both

Medical History

Additional space is provided at the end of the document for any information that does not fit below.

Please list past medical problems or diagnoses. Check here if NONE

Please list any specialist physicians caring for your child. Check here if NONE

Please list any hospitalizations. Check here if NONE

Surgical History

Please list all surgical procedures your child has had. Check here if NONE

Any complications with anesthesia? *

Yes

Any other surgical complications? *

Yes

Medications

Please list all current medications your child is taking. Check here if NONE

Allergies

Please list any medication allergies/adverse reactions. Check here if NONE KNOWN

Please list any food/environmental allergies. Check here if NONE KNOWN

Family History

Please mark any family member ever having the problem/disorder listed below.

	Mother	Father	Brother	Sister	Maternal Grandmother	Maternal Grandfather	Paternal Grandmother	Paternal Grandfather	Aunt	Uncle	N/A
Allergy
Anesthesia Problem
Asthma
Bleeding Disorder
Cancer
Depression
Diabetes
Ear Infections
Ear Tubes
Hearing Loss
High Blood Pressure
High Cholesterol
Heart Disease
Kidney Disease
Snoring / Sleep Apnea
Tonsil Infections
Sinus Infections
Migraines
Thyroid Disease
Hydrocephalus

Ear/Nose/Throat? *	Yes No
Cardiovascular? *	Yes No
Respiratory? *	Yes No
Gastrointestinal? *	Yes No
Genitourinary? *	Yes No
Musculoskeletal? *	Yes No
Skin? *	Yes No
Neurological? *	Yes No
Psychiatric/Behavioral? *	Yes No
Endocrinological? *	Yes No
Hematological/Lymphatic? *	Yes No
Allergic/Immunologic? *	Yes No

New Patient Registration

Patient Demographics

Parent's Information

Parent 2 Information

Emergency Contacts (please provide 2)

Patient Medical History

Birth History:

Medical History

Surgical History

Medications

Allergies

Family History

Social History

Review of Systems

Prenatal and birth History

Hearing History

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