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.
Current health concerns: _______________________________________________________
School: ___________________, Grade: _______, Special education/Resource class: _________
Educational concerns: ______________________
Form filled by _____________, Relationship to patient: ________________