Adolescent Medical History Form

Attachment 10b

Adolescent Medical History Form

Centers for Disease Control and Prevention Registry of Unexplained Fatiguing Illnesses and Chronic Fatigue Syndrome (CFS)

Adolescent Medical History Form

Affix Case ID Label Here

Date: _____/_____/______

Time: ___________am/pm

1. If you have to list your child’s three major health problems, what would they be? Please start with what bothers you the most about your child’s health.

Problem/Complaint/Concern	When did this problem start?	Does your child still have this health problem?
1.	/ MONTH YEAR	Yes No
2.	/ MONTH YEAR	Yes No
3.	/ MONTH YEAR	Yes No

1a. From the time these problems began until now, how have they changed? If there is such a thing as a typical episode, please describe it. If your child has no problems, go to question 2.

Problem 1.

Problem 2.

Problem 3.

PAST MEDICAL HISTORY

2. Before having the problems discussed above, how would you describe your child’s health? (Circle your answer).

Poor Fair Good Very Good Excellent

3. Has your child had any major health problems? Please include problems that made your child go to the doctor more often (not just for “check ups”), go to a hospital, or take medications. These problems include bad infections, reactions to immunizations or vaccinations, and other serious medical problems.

₁ Yes

₂ No → IF NO, GO TO QUESTION 4.

3a. Please describe these health problems your child has had and write below how old your child was when he or she had the health problem. (If you don’t remember your child’s age, give his or her approximate age or think of political or historic events that were happening at that time to help you remember.) If problems or bad reactions to immunizations happened more than once, list them separately. If you need more space, use another sheet of paper.

Health problems	Age when problem occurred
1.
2.
3.
4.
5.
6.
7.
8.

4. Has your child ever had any serious injuries, such as head injury, broken bones, burns or others that required visiting your child’s doctor, an emergency room, or being hospitalized?

₁ Yes

₂ No → IF NO, GO TO QUESTION 5

4a. Please describe your child’s injuries and ages at which the injuries occurred. If you need more space, please use another sheet of paper.

Description of Injury	Age at which your child was injured
1.
2.
3.
4.
5.
6.
7.
8.

5. Has your child ever had other surgeries or hospitalizations? Please do not include the illnesses or injuries you described in item 4 above?

₁ Yes

₂ No → IF NO, GO TO QUESTION 6

5a. Please describe your child’s surgeries and hospitalizations. Please include the age at the time of the surgery or hospitalization. If you need more space, please use another sheet of paper.

Description of Surgery/Hospitalization	Age at Surgery/ Hospitalization
1.
2.
3.
4.
5.
6.
7.
8.

6. In the last year, did your child’s weight change a lot?

₁ Yes ₂ No → IF NO, GO TO QUESTION 7

6a. Did your child intend to gain or lose this weight?

₁ Yes ₂ No

6b. How much weight did your child gain in the last year? ______ pounds

6c. How much weight did your child lose in the last year? ______ pounds

7. The rest of this questionnaire is about health history. For each condition or health problem your child has had, please tell us the age at which it began and whether your child has had this condition or illness in the past 12 months. The clinic doctor and nurse will review your completed form with you and your child during your clinic appointment.

Has your child ever had this condition or illness?		If “YES”:		DOCTOR/NURSE USE ONLY
		How old was your child when he or she first had this condition?	Has your child had this condition in the last 12 months?
7a. Asthma	Yes No (SKIP TO 7b)	AGE: ____	Yes No	Ask about the allergens.
7b. Sudden, severe swelling of the face, mouth, and throat (Quincke's edema)	Yes No (SKIP TO 7c)	AGE: ____	Yes No	Ask about the allergens.
7c. Anaphylactic shock	Yes No (SKIP TO 7d)	AGE: ____	Yes No	Ask about the allergens.
7d. Other allergies	Yes No (SKIP TO 8a)	AGE: ____	Yes No	Ask about the allergens
7e. What other allergies has your child had?				Ask about the allergens.
Skin
8a. Eczema	Yes No (SKIP TO 8b)	AGE: ____	Yes No
8b. Hives	Yes No (SKIP TO 8c)	AGE: ____	Yes No
8c. Skin rashes	Yes No (SKIP TO 8d)	AGE: ____	Yes No
8d. Skin discoloration or swelling	Yes No (SKIP TO 8e)	AGE: ____	Yes No
8e. Other skin problems	Yes No (SKIP TO 9a)	AGE: ____	Yes No
8f. What other skin problems has your child had?
Head
9a. Headaches (for example, tension headaches, migraines)	Yes No (SKIP TO 10a)	AGE: ____	Yes No
Eyes
10a. Glaucoma	Yes No (SKIP TO 10b)	AGE: ____
10b. Eye infection	Yes No (SKIP TO 10c)	AGE: ____	Yes No
10c. Cataract	Yes No (SKIP TO 10d)	AGE: ____
10d. Other eye problems	Yes No (SKIP TO 11a)	AGE: ____	Yes No
10e. What other eye problems has your child had?
Ears, Nose, Mouth and Throat
11a. Problems hearing	Yes No (SKIP TO 11b)	AGE: ____	Yes No
11b. Ringing in your child’s ears	Yes No (SKIP TO 11c)	AGE: ____	Yes No
11c. Ear infections	Yes No (SKIP TO 11d)	AGE: ____	Yes No
11d. Problems with a stuffy nose or drainage from his or her nose to the throat.	Yes No (SKIP TO 11e)	AGE: ____	Yes No
11e. Sores in your child’s mouth or nose	Yes No (SKIP TO 11f)	AGE: ____	Yes No
11f. Problems with dry mouth	Yes No (SKIP TO 11g)	AGE: ____	Yes No
11g. Gum disease (for example: bleeding gums, gum recession)	Yes No (SKIP TO 11h)	AGE: ____	Yes No
11h. Problems swallowing or the feeling of a lump in his or her throat	Yes No (SKIP TO 12a)	AGE: ____	Yes No
Neck
12a. Tenderness or pain in your child’s neck	Yes No (SKIP TO 13a)	AGE: ____	Yes No
Digestive System
13a. Poor appetite Poor appetite	Yes No (SKIP TO 13b)	AGE: ____	Yes No
13b. Excessive appetite	Yes No (SKIP TO 13c)	AGE: ____	Yes No
13c. Heartburn or gastro-esophageal reflux (GER)	Yes No (SKIP TO 13d)	AGE: ____	Yes No
13d. Gastritis or ulcer	Yes No (SKIP TO 13e)	AGE: ____	Yes No
13e. Blood in bowel movements	Yes No (SKIP TO 13f)	AGE: ____	Yes No
13f. Hemorrhoids	Yes No (SKIP TO 13g)	AGE: ____	Yes No
13g. Inflammatory bowel disease, ulcerative colitis or Crohn’s disease	Yes No (SKIP TO 13h)	AGE: ____	Yes No
13h. Hepatitis	Yes No (SKIP TO 13i)	AGE: ____	Yes No
13i. Cirrhosis	Yes No (SKIP TO 13j)	AGE: ____	Yes No
13j. Gallbladder problems	Yes No (SKIP TO 13k)	AGE: ____	Yes No
13k. Recurring or persistent nausea or vomiting	Yes No (SKIP TO 13l)	AGE: ____	Yes No
13l. Recurring or persistent diarrhea	Yes No (SKIP TO 13m)	AGE: ____	Yes No
13m. Recurring or persistent constipation	Yes No (SKIP TO 13n)	AGE: ____	Yes No
13n. Chronic or persistent bloating	Yes No (SKIP TO 13o)	AGE: ____	Yes No
13o. Other problems with digestive system	Yes No (SKIP TO 13q)	AGE: ____	Yes No
13p. What other problems has your child had with his or her digestive system?
13q. High cholesterol	Yes No (SKIP TO 13r)	AGE: ____	Yes No
13r. High triglycerides	Yes No (SKIP TO 14a)	AGE: ____	Yes No
Chest: Heart and Lungs
14a. Chronic cough	Yes No (SKIP TO 14b)	AGE: ____	Yes No
14b. Chronic bronchitis	Yes No (SKIP TO 14c)	AGE: ____	Yes No
14c. Chronic obstructive pulmonary disease (COPD) or emphysema	Yes No (SKIP TO 14d)	AGE: ____	Yes No
14d. Shortness of breath when inactive (sitting or in bed)	Yes No (SKIP TO 14e)	AGE: ____	Yes No
14e. Shortness of breath when your child walks, runs, or climbs stairs	Yes No (SKIP TO 14f)	AGE: ____	Yes No
14f. Fluid in your child’s lungs	Yes No (SKIP TO 14g)	AGE: ____	Yes No
14g. Pneumonia	Yes No (SKIP TO 14h)	AGE: ____	Yes No
14h. Wheezing	Yes No (SKIP TO 14i)	AGE: ____	Yes No
14i. Chest pain	Yes No (SKIP TO 14j)	AGE: ____	Yes No
14j. High blood pressure	Yes No (SKIP TO 14k)	AGE: ____	Yes No
14k. Low blood pressure	Yes No (SKIP TO 14l)	AGE: ____	Yes No
14l. Heart problems or irregular heart beat (arrhythmia)	Yes No (SKIP TO 14m)	AGE: ____	Yes No
14m. Problems with your child’s arteries	Yes No (SKIP TO 14n)	AGE: ____	Yes No
14n. Swelling of your child’s legs	Yes No (SKIP TO 14o)	AGE: ____	Yes No
14o. Feet or hands get cold very easily	Yes No (SKIP TO 14p)	AGE: ____	Yes No
14p. Other lung, heart or vascular problems?	Yes No (SKIP TO 15a)	AGE: ____	Yes No
14q. What other lung, heart or vascular problems has your child had?
Urinary Tract
15a. Bladder or kidney infection, or urinary tract infection (UTI)	Yes No (SKIP TO 15b)	AGE: ____	Yes No
15b. Kidney stones	Yes No (SKIP TO 15c)	AGE: ____	Yes No
15c. Frequent need to urinate (pee)	Yes No (SKIP TO 15d)	AGE: ____	Yes No
15d. Problems with starting to urinate (pee)	Yes No (SKIP TO 15e)	AGE: ____	Yes No
15e. Burning sensation or pain when urinating (peeing)	Yes No (SKIP TO 15f)	AGE: ____	Yes No
15f. Other kidney or urinary problems	Yes No (SKIP TO 15h)	AGE: ____	Yes No
15g. What other kidney or urinary problems has your child had?
15h. How many times per night, on average, does your child get up to go to the bathroom? ___ times
Nervous System
16a. Dizziness or vertigo (“head spinning”)	Yes No (SKIP TO 16b)	AGE: ____	Yes No
16b. Feeling faint or fainting	Yes No (SKIP TO 16c)	AGE: ____	Yes No
16c. Poor balance	Yes No (SKIP TO 16d)	AGE: ____	Yes No
16d. Poor coordination	Yes No (SKIP TO 16e)	AGE: ____	Yes No
16e. Numbness or tingling on face, trunk, arms or legs	Yes No (SKIP TO 16f)	AGE: ____	Yes No
16f. Loss of consciousness (other than fainting)	Yes No (SKIP TO 16g)	AGE: ____	Yes No
16g. Seizures	Yes No (SKIP TO 16h)	AGE: ____	Yes No
16h. Encephalitis	Yes No (SKIP TO 16i)	AGE: ____	Yes No
16i. Meningitis	Yes No (SKIP TO 16j)	AGE: ____	Yes No
16j. Other neurological problems	Yes No (SKIP TO 17a)	AGE: ____	Yes No
16k. What other neurological problems has your child had?
Musculo-skeletal System
17a. Pain in muscles, tendons or joints	Yes No (SKIP TO 17b)	AGE: ____	Yes No
17b. Stiffness in joints or back	Yes No (SKIP TO 17c)	AGE: ____	Yes No
17c. Carpal tunnel syndrome or other tendon problems	Yes No (SKIP TO 17d)	AGE: ____	Yes No
17d. Bone problems (including osteopenia and osteoporosis)	Yes No (SKIP TO 17e)	AGE: ____	Yes No
17e. Muscle weakness	Yes No (SKIP TO 17f)	AGE: ____	Yes No
17f. Systemic Lupus Erythematosus	Yes No (SKIP TO 17g)	AGE: ____	Yes No
17g. Rheumatoid Arthritis	Yes No (SKIP TO 17h)	AGE: ____	Yes No
17h. Other arthritis	Yes No (SKIP TO 17j)	AGE: ____	Yes No
17i. What other arthritis has your child had?
17j. Fibromyalgia	Yes No (SKIP TO 18a)	AGE: ____	Yes No
Endocrine System
18a. Diabetes or high blood sugar	Yes No (SKIP TO 18b)	AGE: ____	Yes No
18b. Problems with his or her thyroid gland	Yes No (SKIP TO 18c)	AGE: ____	Yes No
18c. Other endocrine problems	Yes No (SKIP TO 19a)	AGE: ____	Yes No
18d. What other endocrine problems has your child had?
Blood
19a. Anemia, low hemoglobin, “thin blood,” or low number of red blood cells	Yes No (SKIP TO 19b)	AGE: ____	Yes No
19b. Easy bruising or bleeding	Yes No (SKIP TO 19c)	AGE: ___	Yes No
19c. Very low white blood cell count	Yes No (SKIP TO 19d)	AGE: ___	Yes No
19d. Very high white blood cell count	Yes No (SKIP TO 19e)	AGE: ___	Yes No
19e. Leukemia	Yes No (SKIP TO 19f)	AGE: ____	Yes No
19f. Hodgkin's Lymphoma	Yes No (SKIP TO 19g)	AGE: ____	Yes No
19g. Lymphoma (non-Hodgkin’s)	Yes No (SKIP TO 19h)	AGE: ____	Yes No
19h. Swollen lymph nodes (for example, around your child’s neck, or in his or her groin, or armpits or other places on your child’s body)	Yes No (SKIP TO 19i)	AGE: ____	Yes No
19i. Infectious mono-nucleosis (also called “Mono”)	Yes No (SKIP TO 19j)	AGE: ____	Yes No
19j. Blood diseases (such as sickle cell anemia, thalassemia or hemophilia)	Yes No (SKIP TO 19l)	AGE: ____	Yes No
19k. What blood diseases has your child had? (Check all that apply.) Sickle cell anemia Thalassemia Hemophilia Other, please specify: Age started:
19l. Has your child ever had blood transfusions?	Yes No (SKIP TO 20a)	AGE: ____		For what reason

20a. Are there any other particular problems or concerns related to your child’s health that you would like to mention?

₁ Yes → GO TO QUESTION 20b

₂ No → GO TO NEXT PAGE

20b. Please describe the problems or concerns below. Use more pages if necessary.

Other diseases (or health problems/ concerns)	How old was your child when this problem began?	Does your child still have this problem?	DOCTOR/NURSE USE ONLY
1.	AGE: ______	Yes No
2.	AGE: ______	Yes No
3.	AGE: ______	Yes No
4.	AGE: ______	Yes No
5.	AGE: ______	Yes No
6.	AGE: ______	Yes No

Additional notes to questions

If you wish to explain more about a condition or illness that your child had, please use the space provided below (Remember to enter the number of the question to which your explanation applies).

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