PEDIATRIC SURGICAL ASSOCIATES
 

Patient History
Date: Time:
Name:    MI:  Last Name:
Birthday:        
Birth Weight: Current Weight:
Primary Care Doctor: Gender:
Chief Complaint (In your own words what is your child's condition?)    
Neonatal History
Prematurity: (Gestational Age   Weeks )
Respiratory Problems: Feeding Disorders:
Heart Disease: Other:
Jaundice: Other:
Other Medical History
List other significant medical problems recent exposure to communicable disease:
Disease:   Approximate Exposure Date:
Measles:
Chicken Pox:
Tuberculosis:
Other:

If more room is needed when listing medical problems, medications, allergies hospital-izations and surgeries please write in the text box.
 
List Any Medication Currently Taking:
List Drug Allergies and Type of Reaction:
List Previous Hospitalization (Date & Reasons)
List Previous Surgeries:
Emergency Contact:
 		Emergency Phone:
 
Has Your Child Had A Problem With General Anesthesia? NO:    YES: Explain:
Does Your Child Have Any Problems With Bleeding? NO:    YES: Explain:
Has Your Child Had Transfusions? NO:    YES: Explain:
If So For What Reason? How Many?

What Is Your Child's Diet? (Indicate Type Of Milk Or Forula, Volume & Frequency).
Additional Information
Additional Notes:
You must click 'Yes' to continue:
I certify that the information entered above is correct to the best of my knowledge.
   

1120 W. La Veta Ave. Suite 100
Orange, CA 92868
Office: 714-361-4480
 Fax: 714-361-4490
Email: office@psaoc.org

27800 Medical Center Road, Suite 138
Mission Viejo, CA 92691
Office: 714-361-4480
 Fax: 714-361-4490
Email: office@psaoc.org