Gerald R. Jerkins MD
UT Le Bonheur Pediatric Specialists
Memphis Tennessee

Medical History

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Personal Information

*Patient Name
 *Birth Date
 Drug Allergies
Approximate Weight
 Primary Care Physician
  

Person Completing This Form
Relationship To Patient
*Reason For Visit
Additional Medical Tests / X-Rays / Medications Relating To Problem
Past Medical History / Medical Conditions (Past surgeries / Hospitalizations, Major health problems)
Current Medications
Immunizations up to date?
Yes No

Family Medical History

UTI? Yes No
Kidney/ bladder reflux? Yes No
Other kidney problems? Yes No
Other major health problems? Yes No
Daytime wetting accidents? Yes No
How many days a week?
Frequency Yes No
Urgency Yes No
Painful Urination Yes No
Previous urinary infections? Yes No
Nighttime wetting accidents? Yes No
How many nights a week?
Family history? Yes No
Who?
Previously Treated? Yes No
Alarms or Medication? Alarms Medication

Social History

Child lives with?
Other
Grade in School
Is there anything else we should know to better care for this patient?