Medical History
From the Handbook, it should have:
- allergies
- adverse drug reactions
- immunizations
- current meds with dosages
- recurrent headaches
- congenital birth defects
- seizures
- developmental delays
- behavioral/learning problems
- hx of blood transfusions
- hx of abnormal bleeding
- problems with
o heart
o kidney
o liver/GI
o endocrine system
o breathing/lungs
o hearing
o vision
- history of
o cancers, tumors, blood dyscrasias
o hospitalizations, surgeries, injuries
o bacterial/viral infections (???)
o name/address of physician
o date of last physical exam
o substance abuse
o STD
o Pregnancy
o Any other issues?
- Family/social history
Should be consulted and updated at every visit. A new signed med hx should be obtained at every recall visit.
Needs to be signed and dated by legal guardian, and signed by person reviewing.
No comments:
Post a Comment