NAME: ______________________________________ DOB: ______________ RETURNING PATIENT INFORMATION
We appreciate the opportunity to partner with you in the health of your child. We ask you to complete this information carefully and legibly. Thank you!
List all current medications with dose and frequency:
Do you have any Asthma Action Plan drugs on hand at home? (please circle all that apply.) Albuterol Xopenex Orapred or Prednisolone Prednisone Medrol In the last week or two, have there been changes in health including flu or colds? ____NO ____YES (please describe) _______________________________________________________________________________
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SINCE YOUR LAST VISIT Since last visit, have there been any respiratory complaints which caused:
Hospitalizations? ____NO ____YES When/How Many? __________________________________
Emergency Room Visits? ____NO ____YES When/How Many? _______________________________
Acute Doctor Visits? ____NO ____YES When/How Many? ____________________________
Courses of Oral Steroids? ____NO ____YES When/How Many? ___________________________
Since last visit, describe asthma control during a typical week when child is not ill:
Cough? ____ NONE ____OCCASIONAL ___FREQUENT ____CONSTANT
Activity/Exercise Interference? ____ NONE ____OCCASIONAL ___FREQUENT ____CONSTANT
Sleep Disturbance? ____ NONE ____OCCASIONAL ___FREQUENT ____CONSTANT
Need for Albuterol/Xopenex? ____ NONE ____OCCASIONAL ___FREQUENT ____CONSTANT
Since last visit, please describe the following:
Allergic Rhinitis/Hay Fever? _____DON’T HAVE ______ CONTROLLED _____ NOT CONTROLLED
Atopic Dermatitis/Eczema? _____DON’T HAVE ______ CONTROLLED _____ NOT CONTROLLED
Gastroesopheal Reflux? _____DON’T HAVE ______ CONTROLLED _____ NOT CONTROLLED
SINCE YOUR LAST VISIT Please list any recent symptoms or complaints in the following areas, since last visit: Health Overall – for example change in appetite, chills, fatigue, weight gain or loss, etc.
____NO _____YES (describe) __________________________________________________________________
Eyes – for example visual changes, blurred vision, eye drainage, sensitivity to light, etc.
____NO _____YES (describe) __________________________________________________________________
Ears, Nose, and Throat – for example sore throat, hearing changes, sinus drainage, etc.
____NO _____YES (describe) __________________________________________________________________
Heart – for example heart murmur, heart palpitations, chest tightness, dizziness, etc.
____NO _____YES (describe) __________________________________________________________________
Stomach and Intestines – for example abdominal pain, change in stools, heartburn, indigestion
____NO _____YES (describe) __________________________________________________________________
Bladder or Kidney – for example urinary problems, blood in urine, frequent bladder infections, etc.
____NO _____YES (describe) __________________________________________________________________
Muscle or Skeleton – for example arthritis, back pain, joint stiffness or pain, weakness, etc.
____NO _____YES (describe) __________________________________________________________________
Skin – for example change in moles, acne, rashes, sores, etc.
____NO _____YES (describe) __________________________________________________________________
Neurological – for example fainting, headaches, memory problems, numbness or tingling, etc.
____NO _____YES (describe) __________________________________________________________________
Psychological – for example anxiety, depression, mood swings, poor concentration, etc.
____NO _____YES (describe) __________________________________________________________________
Diabetes/Thyroid – for example cold or heat intolerance, hair loss, excessive thirst, etc.
____NO _____YES (describe) __________________________________________________________________
Bleeding/Anemia – for example blood clotting problems, easy bruising, excessive bleeding, etc.
____NO _____YES (describe) __________________________________________________________________
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PATIENT MEDICAL HISTORY – SINCE BIRTH Please list any symptoms, complaints, or diagnosis in the following areas since birth: Health Overall? ____NO ____YES (describe) __________________________________________________ Eyes? ____NO ____YES (describe) ___________________________________________________________ Ears, Nose, and Throat? ____NO ____YES (describe) _________________________________________ Heart? ____NO ____YES (describe) __________________________________________________________ Stomach and Intestines? ____NO ____YES (describe) ________________________________________ Bladder or Kidney? ____NO ____YES (describe) _____________________________________________ Muscle or Skeleton? ____NO ____YES (describe) _____________________________________________ Skin? ____NO ____YES (describe) ____________________________________________________________ Neurological? ____NO ____YES (describe) __________________________________________________ Psychological? ____NO ____YES (describe) ________________________________________________ Diabetes/Thyroid? ____NO ____YES (describe) ______________________________________________ Bleeding/Anemia? ____NO ____YES (describe) _____________________________________________ Other Comments? _________________________________________________________________________
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PAST SURGERIES? _____None _____Yes, Please describe: __________________________
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PATIENT SOCIAL ENVIRONMENT Please circle the answer which best represents the patient’s current living arrangements?
With: PARENTS MOTHER FATHER SPLIT TIME GRANDPARENT(S)
Is your family involved with the Department of Human Services in any capacity? _____NO
If yes, please describe: _________________________________________________________
Where does patient spend time during the day?
DAYCARE: (Number of days during week?) __________
PRESCHOOL: (Number of days during week?) __________
SCHOOL: (Number of days during week?) __________
BROTHERS? ____None Yes-Ages: ________ SISTERS? ____None Yes-Ages: _______ PATIENT ENVIRONMENTAL HISTORY – Information on home and neighborhood
CITY: ________________________________________ HOME?: SINGLE-FAMILY What year was the house built? ________
BASEMENT?: NONE UNFINISHED FINISHED Is the basement ____DAMP or ____DRY? HOME CLIMATE CONTROL?: CENTRAL AIR WINDOW UNIT
CENTRAL FORCED HEAT RADIATOR HEAT BASEBOARD HEAT FIREPLACE
WOOD BURNING STOVE AIR PURIFIERS OTHER _______________________________
PATIENT’S BEDROOM: NUMBER OF BEDS IN ROOM ______
BEDS HAVE DUST MITE COVERS ____NO ____YES
NUMBER OF PEOPLE SLEEPING IN ROOM _______
PETS?: NONE CAT(S) ______ DOG(S) ______ OTHER: __________
DO PETS HAVE ACCESS TO BEDROOM? ____________________
INDUSTRIAL OR AGRICULTURAL POLLUTION IN NEIGHBORHOOD?: _____NO
If yes, please describe? __________________________________________________________
SMOKER EXPOSURE: ____NO _____YES Who? ___________________________ Does smoker limit direct contact by smoking outdoors only? ____________________ Does patient smoke? ____NO _____YES How often? ___________________________ PRIMARY CARE PHYSICIAN?: _________________________________________ Location?: ____________________________________________ PREFERRED PHARMACY?: __________________________________________ Location?: ____________________________________________ FAMILY MEDICAL HISTORY - Please circle any that apply for patient’s immediate family and/or grandparents RESPIRATORY EYES/VISION EARS, NOSE, STOMACH/ INTESTINES BLADDER/ SKELETON NEUROLOGIC PSYCHIATRIC ENDOCRINE Other? _______________________________________________________________________________________________________ Is child adopted? _____NO ______YES
Theory-guided Content Analysis in Architectural Research Case: The Colouration of the Home During the Post-War Reconstruction Period: The Everyday and Architecture. Aulikki HERNEOJA Head of Laboratory of Art end Design, Doctor of Science (Technology), Architect University of Oulu, Department of Architecture Postal address: Aulikki Herneoja, University of Oulu, Department of
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