MEDICAL  HISTORY  PATIENT  PROFILE

 

Parents/Guardians seeking medical care assistance for their child must download these forms, carefully following instructions. This Medical History Patient Profile is  very important!   

Please do not ignore any question.

Click Here  For A Downloadable PDF Copy Of This Medical Profile Form 

Questions? Email: ICMFHope@Aol.Com

 

DATE: _______________________________________

CATEGORY___________________________________

(See Below)

LAST NAME: _______________________________ FIRST: ____________________________________

MIDDLE: __________________________________

DOB:_____________________________________

 

ADDRESS:_______________________________________

PHONE:___________________EMAIL:________________

 

MOTHER:_______________________DOB:___________

FATHER:_______________________DOB:____________

(Circle One: Married - Divorced - Widowed - Common Law)

VACCINATIONS UP TO DATE? ___________

LIST SERIOUS ILLNESSES/DATES ON REVERSE SIDE OF THIS FORM __________________________________________________

CURRENT HT: ________ WT: ______________ HEENT: _____________ EARS: ___________ DENTAL PROBLEMS?: ______________________

PHYSICIAN: _________________________________________________

OTHER: _____________________________________________________

HOW WAS THIS CHILD BROUGHT TO ICMF's ATTENTION? ______________________________________________________________

MOTHER'S INFORMATION - AGE AT BIRTH: _______ MEDS TAKEN DURING PREGNANCY: _________________________________________

ETH?_______ TOB? ________ OTHER? _________________ MISCARRIAGES? _________ STILL BORNS?____________

# THIS CHILD? ________

FULL TERM? _______ IF NOT, # MONTHS? __________ WT. OF THIS CHILD AT BIRTH:_________TOTAL # OF CHILDREN_______________

ANY ADDITIONAL INFOMATION WE NEED TO KNOW. USE REVERSE SIDE IF NECESSARY:__________________________________________

______________________________________________________________

ANY FAMILY HISTORY OF: THIS MEDICAL PROBLEM?______________________________________________________

SEIZURES? _______________ HEART?______________ IF SO LIST:

____________________________________________________________

____________________________________________________________

____________________________________________________________

* Categories (Indicate Category Numvber Above)

1 - Orthopedic - Explain: ___________________________________________________________

2 - Heart Evaluation? _____________ Echo? _______________

X-Rays? ______________ Other: _________________________________________________________

3 - Spina Bifida - Location: ______________________________________________________________

4 - Cleft Lip/Palate (Circle One) LIP: Right/Left/Bilateral -

PALATE: Right/Left/Bilateral - Notes: ____________________________________________________________

5 - Plastic Surgery - Explain: ___________________________________________________________

6 - Other: ___________________________________________________________

A CLOSE UP PHOTO MUST BE TAKEN WITH WILL GIVE A FACE VIEW OF CHILD (i.e., Passport) AND, WHERE APPROPRIATE, CLOSE UP PHOTOS SHOWING MEDICAL PROBLEM FOR WHICH ASSISTANCE IS SOUGHT. IF THE MEDICAL PROLEM IS AN 'INTERNAL' ONE, (i.e., Heart), WE MUST HAVE X-RAYS, EKG AND IT'S READING AS WELL AS ECHOCARDIOGRAM AND IT'S READING. READINGS ALONG WILL 'NOT' SUFFICE; WE MUST HAVE THE ACTUAL EKG AND ECHOCARDIOGRAM. WE MUST ALSO HAVE A CURRENT BLOOD TEST, SICKLE CELL TESTS AND HIV TEST RESULTS.

KINDLY EMAIL US WITH ANY QUESTIONS: ICMFHope@Aol.Com