Health intake form

HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential and will become part of your care record. PERSONAL HEALTH HISTORY
Medications (List all prescribed drugs and over-the-counter drugs, such as acetaminophen and vitamins)
(eg. 150mg, via g-tube, twice daily) My child will not take any medications while at The Ottawa Rotary Home
Allergies
Reaction (eg. Difficulty breathing & hives) Treatment (eg. Epinephrine, Call 911) My child does not have any known allergies CRS-014 Health History Questionnaire 20/05/09 Childhood Illness
Childhood Illnesses: Measles Mumps Rubella Chickenpox Rheumatic Fever Polio Immunization
A copy of my child’s immunization record is attached
Surgeries
Surgery & Reason (eg. G-tube insertion – unsafe to swallow liquids)
Hospitalizations
Reason for Admission (eg. pneumonia) CURRENT HEALTH CONCERNS
Seizures
Does you child have seizures?
For each type of seizure complete a separate section below and check off all that apply.

Type of Seizure #1
During the seizure
your child is usually
First signs of the
seizure are typically
CRS-014 Health History Questionnaire 20/05/09 Body movement
during the seizure
Body parts normally
involved
consciousness during
seizure
Breathing during
Post seizure state

Type of Seizure #2
During the seizure
your child is usually
First signs of the
seizure are typically
Body movement
during the seizure
Body parts normally
involved
consciousness during
seizure
Breathing during
Post seizure state

Type of Seizure #3
During the seizure
your child is usually
First signs of the
seizure are typically
CRS-014 Health History Questionnaire 20/05/09 Body movement
during the seizure
Body parts normally
involved
consciousness during
seizure
Breathing during
Post seizure state

Specialized Medical Devices
Please indicate if your child uses any of the following medical devices. Is a nurse required to perform care for your child’s medical device? Please give a detailed description of any special care that is required for your child’s medical device. HEALTH CARE PROVIDERS
Specialty
Contact Number
CRS-014 Health History Questionnaire 20/05/09 ADVANCED DIRECTIVES
Does your child have any Advanced Directives? Does your child have any specialized doctor’s orders/plan of
Additional Information

DENTAL HISTORY
What was the date of your child’s last dental visit:
Does your child have any dental appliances i.e. braces, retainer? Yes No
If you answered yes to the above question please describe appliance and any special care
requirements:

CRS-014 Health History Questionnaire 20/05/09 Dental Surgeries
Surgery & Reason (eg. wisdom teeth removal – impacted teeth) Does your child experience acute pain or chronic pain, or both? What are the most common causes of your child’s pain? How does your child express pain? (Please check off all that apply) Communication
Facial expression
Leg or general body
movements
Activity or social
interactions
Cry or vocalization
Consolability
Other changes
Other measures used
to relieve your child’s
pain?
CRS-014 Health History Questionnaire 20/05/09 OTTAWA ROTARY HOME – PAIN SCALE
Please complete the following numeric pain scale using the terms on the previous page to identify your child’s expression of pain at each level. Zero indicates your child’s behaviour/mood when they are in no pain and ten indicates your child’s behaviour/mood when they are in the worst pain ever. Above each number on the pain scale indicate your child’s expression of pain and below that number indicate how you would attempt to relieve your child’s pain at that level. Expression of
Pain Score
Management
CRS-014 Health History Questionnaire 20/05/09 I/We certify that the above information is accurate and complete. Questions and points for clarification by parents. CRS-014 Health History Questionnaire 20/05/09

Source: http://www.rotaryhome.on.ca/wp-content/uploads/2013/02/Health-History-Questionnaire.pdf