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. 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