Columbus Children’s Healthcare Patient Name: Ha muerto alguno de los hermanos del nino/nina? Si Si contesto Si, explique: □No □ ALERGIAS: Incluyendo cual-Please list all of the allergies, including any allergic reactions to drugs: FAMILY HISTORY: Check any illnesses that the child or members of the child’s family have had: Child Family Child Family Frequent Ear Infections Diabetes □ □ □ □ Frequent Throats Kidney/Bladder Problems □ □ □ □ Croup Seizures/Convulsions □ □ □ □ Mumps, Measles, Chicken Pox Early Heart Disease □ □ □ □ Wheezing/Asthma High Cholesterol □ □ □ □ Pneumonia High Pressure □ □ □ □ Eye Problems Lung Disease/Tuberculosis □ □ □ □ Dental Problems Sexually Transmitted Disease □ □ □ □ Hearing Problems Alcohol/Drug use □ □ □ □ Hay Fever/Seasonal Allergies Cancer □ □ □ □ Emotional Disorders/Suicide Attempt Eczema/Skin Problems □ □ □ □ Anemia/Blood Problems Other Illnesses: □ □ □ □ DEVELEPMENT AND BEHAVIORAL ISSUES HEALTH AND SAFETY ISSUES Did the child sit alone by 7 months? Yes No Are there any guns in the child’s house? Yes No Did the child walk alone by 14 months? Yes No Does the child use a toothbrush daily? Yes No Did the child say 3 words by 15 months? Yes No Does the child use a car seat or seatbelt all of the time? Yes No Is the child doing well in school? Yes No Are there smoke detectors in the home? Yes No Does the child get along with other Is the hot water temperature less than children? Yes No 125°? Yes No Circle any of the following which the child has: Do you or someone in the household Nightmares/Sleep Problems Thumb Sucking know CPR? Yes No Irritable/Bad Temper Bed Wetting Toilet Training Problems Speech Issues Discipline Problems Breath Holding
Columbus Children’s Healthcare Patient Name: Ha muerto alguno de los hermanos del nino/nina? □No □ Si Si contesto Si, explique: ALERGIAS: Incluyendo cual-Please list all of the allergies, including any allergic reactions to drugs: FAMILY HISTORY: Check any illnesses that the child or members of the child’s family have had: Child Family Child Family □ □ Frequent Ear Infections □ □ Diabetes □ □ Frequent Throats □ □ Kidney/Bladder Problems □ □ Croup □ □ Seizures/Convulsions □ □ Mumps, Measles, Chicken Pox □ □ Early Heart Disease □ □ Wheezing/Asthma □ □ High Cholesterol □ □ Pneumonia □ □ High Pressure □ □ Eye Problems □ □ Lung Disease/Tuberculosis □ □ Dental Problems □ □ Sexually Transmitted Disease □ □ Hearing Problems □ □ Alcohol/Drug use □ □ Hay Fever/Seasonal Allergies □ □ Cancer □ □ Emotional Disorders/Suicide Attempt □ □ Eczema/Skin Problems □ □ Anemia/Blood Problems □ □ Other Illnesses: DEVELEPMENT AND BEHAVIORAL ISSUES HEALTH AND SAFETY ISSUES Did the child sit alone by 7 months? Yes No Are there any guns in the child’s house? Yes No Did the child walk alone by 14 months? Yes No Does the child use a toothbrush daily? Yes No Did the child say 3 words by 15 months? Yes No Does the child use a car seat or seatbelt all of the time? Yes No Is the child doing well in school? Yes No Are there smoke detectors in the home? Yes No Does the child get along with other Is the hot water temperature less than children? Yes No 125°? Yes No Circle any of the following which the child has: Do you or someone in the household Nightmares/Sleep Problems Thumb Sucking know CPR? Yes No Irritable/Bad Temper Bed Wetting Toilet Training Problems Speech Issues Discipline Problems Breath Holding
Registration_-_Spanish.docx