prediabetes clinic patient and family history form

Thank you for helping us better understand your concerns. We look forward to providing services to your family. This form is to be used by families after receiving contact from our office indicating that your referral has been accepted. If you have not received a referral to our prediabetes clinic, please talk to your child's primary care physician.

If you have any questions, please contact us at 937-641-3487.

background information

Child's Name:

Gender

Date of Birth:

Your Name:

Relationship to child:

Best Phone Number:

Secondary Phone Number:

Email:

Mother's Name:

Birth date:

Occupation:

Height:

Weight:

Father’s Name:

Birth date:

Occupation:

Height:

Weight:

Names of living brothers and sisters and their birthdates:

Was child adopted?

If yes, at what age?

If adopted, country of origin:

Reason for visit to the hyperinsulinism clinic:

Date of last physical exam:

Does child have a primary care physician/other healthcare providers?

Please list:

parental pregnancy history

Number of pregnancies before this child:

how long was the pregnancy?

Were there any of the following illnesses or problems?

Explain:

Medicines or supplements used during pregnancy:

Smoking while pregnant:

Alcohol while pregnant:

Method of Delivery:

Did baby require?

Did baby have?

At birth:

Weight:

Length:

Apgar score:

Discharge weight:

Length of hospital stay:

Describe any problems with birth or first days of life:

family background

Ethnic origin/Race:

Mother:

Father:

Parent's marital status:

Child lives with:

Guardian name:

Other members of household:

sleep and elimination

How many bowel movements does your child have in a day?

Urination: does your child urinate excessively (10 or more times) during day?

Does your child get up at night almost every night to drink?

Does your child get up at night almost every night to urinate?

How many nights a week does your child wet the bed:

If wet nights occur, how long ago did this start?

Typical Bedtime:

Wake time:

Number of times they wake up in the night:

Does your child snore?

If yes how many nights a week?

Sleep problems (describe):

medical history

Please check the diseases that your child has had and give age:

Other illnesses:

weight history

How much did your child weigh at age (if you remember):

1 year	2 years	5 years	Operations
1 year	2 years	5 years

How old was your child when you noticed a weight problem:

How much weight did your child gain:

Re-order	last year	in last 2 years	Weight	Operations
	last year	in last 2 years	Item weight

more items

Check options

level of concern about your child’s weight

Put mark from 0 to 5 (0 = no concern to 5 = very worried)

Table concerns

Re-order	Person	Level of concern	Name	Weight	Operations
	Person	Level of concern	Name	Item weight

more items

symptoms and signs

Please check yes if your child has any of the following and then explain.

Symptoms table

Re-order	Condition	Yes/No	How many times a week	When did this start	Treatment	Specialist seen	Comments	Weight	Operations
	Condition	Yes/No	How many times a week	When did this start	Treatment	Specialist seen	Comments	Item weight

more items

metabolic syndrome family history

Metabolic table

Re-order	Condition	Relative of the child who has this	How old was person when diagnosed	Treatment (for diabetes write pills, diet or insulin)	Weight	Operations
	Condition	Relative of the child who has this	How old was person when diagnosed	Treatment (for diabetes write pills, diet or insulin)	Item weight

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family weight history

If you or any other of the child’s close relatives has had issues with obesity or weight gain, please comment below (including if they had any weight loss or weight surgery):

child development

At what age did your child:

Re-order	Sit alone	Walk alone	Feed self	Talk (2-3-word sentences)	Dress self	Weight	Operations
	Sit alone	Walk alone	Feed self	Talk (2-3-word sentences)	Dress self	Item weight

more items

Toilet trained:

Re-order	Day	Night	Weight	Operations
	Day	Night	Item weight

more items

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prediabetes clinic patient and family history form

background information

parental pregnancy history

family background

sleep and elimination

medical history

weight history

level of concern about your child’s weight

symptoms and signs

metabolic syndrome family history

family weight history

child development

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