CHITRITA ROY, M.D., P.C.

                 404 A West Mission Avenue, Bellevue, NE 68005                                                                                                               

                 614 N 108 Court, Omaha, NE 68154                                                                                                

                 Phone: 402-991-KIDS (5437), Fax: 402-991-5497, Cell: 402-214-8873, Web: Kids1now.com                                                                                                                                                                                                                                                                                                                                                                                                          


                                   Initial New Patient history form

Name: ________________, DOB: _______________, Today’s date: ___________

List of persons living in the home with the child, Name, relationship, any health problem:

Parents: Mother____________________Bio/Step, Visitation rights if applicable_____________

              Father_____________________Bio/Step, Visitation rights if applicable_____________

Smokers if any living in the house: __________________________________________

Family History: Circle the ones present:

Allergies, Asthma, Heart disease, High BP, High Cholesterol, Anemia, Bleeding Disorder, Liver disease, Kidney Disease, Diabetes,  Epilepsy/ Seizures, Deafness, Blindness, Bed wetting after 10 years of age, Alcohol and drug abuse, ADHD, Autism, Mental disorder, Immune problem, Cancer, HIV/AIDS, congenital malformation or genetic disease.

Birth History: Normal Delivery or C-Section, Term/Pre-term/Post-term/Weeks of gestation____

Mother with any illness/problems with pregnancy ______________, any smoking/alcohol or drug abuse__________________________,

Birth Weight______, Length _______, Complications _________, Breast/Formula fed, type of formula ___________.

Medical History: Circle the ones present:

Developmental delay, Genetic disease, Frequent ear or sinus infection, Hearing or vision problem, Asthma/bronchitis/other lung disease, enlarged tonsils or adenoids, anemia, heart disease, abdominal pain, constipation, food intolerance, liver disease, kidney disease, Diabetes, Thyroid disease, skin problem, Headache, Behavioral problem, ADHD, seizure, neurologic problem.

Surgeries: ___________________

Hospitalizations: _____________

Allergies: ____________________

Current health concerns: _______________________________________________________

School: ___________________, Grade: _______, Special education/Resource class: _________

Educational concerns: ______________________

Form filled by _____________, Relationship to patient: ________________