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1 NORTHERN NEVADA HOPES! your partner in health. PEDIÁTRICA "Historial"de"Salud"Inicial" "!!! FOROFFICEUSEONLY:PLEASECHECKONE PEDIATRICPRIMARYCARE PEDIATRICBEHAVIORALHEALTH NOMBREDELNIÑO SEGUNDONOMBRE APELLIDO EDAD FECHADENACIMIENTO Silospadresnovivenjuntos,osielniñonoviveconsuspadres, cuáleselestadodecustodiadelniño? HISTORIADENACIMIENTO Elpesoalnacer: libras oz Cuandonacióelbebé? Altérmino Temprano Tarde Sitemprano, cuántassemanasdegestación? semanas Lamadretuvoalgunaenfermedadoproblemaconsuembarazo? Sí No Encasoafirmativo,porfavorexplique: Duranteelembarazo,experimentólamadrelosiguiente: Fumar? Sí No BeberAlcohol? Sí No Usardrogasomedicamentos? Sí No Encasoafirmativoalasdrogasomedicamentos, quéycáundo? Fechadeadopción,siprocede): Cómofueentregadoelbebé? Cesárea Vaginal Sicesárea, porqué? Elbebétuvoalgúnproblemadespuésdelnacimiento? Sí No Encasoafirmativo,porfavorexplique: Cómosediolaalimentación? DeMama Botella Elbebévaacasaconlamadredelhospital? Sí No Sino,porfavorexplique: GENERAL Consideraasuniñoaestarenbuenasalud? Sí No Explique: Revised:2/1/15 Page1of3
2 Suhijo/atienealgunacondiciónmédica? Sí No Explique: Suhijo/ahatenidograveslesionesoaccidentes? Sí No Explique: Hasidosuhijo/ahospitalizado? Sí No Explique: Essuniñoalérgicoaalgúnmedicamentoodrogas?Sí No Explique: Tomasuhijo/aalgúnmedicamentoconregularidad? Sí No Explique: DESARROLLO Nombredelaescuelaoguarderíaygradoenlaescuela: Cómoessucompartamientoenlaescuela? Él/ellaharepetidoungradoenlaescuela? Cómoestáél/ellahaciendaenmateriasacadémicas? Esél/ellaenclasesespecialesoderecursos? Estapreocupadoporeldesarrollofisicodesuhijo/a? Sí No Explique: Estapreocupadoporeldesarrollomentaloemocionaldesuhijo/a? Sí No Explique: Estapreocupadoporlafaltadeenfoquedesuhijo/a? Sí No Explique: HISTORIAFAMILIAR Tienealgúnmiembrodelafamiliaqueteníanlosiguiente: Sordera Sí No Quien: Comentarios: Alergias Sí No Quien: Comentarios: Asma Sí No Quien: Comentarios: Tuberculosis Sí No Quien: Comentarios: Enfermedaddelcorazon Sí No Quien: Comentarios: Altapresiónsanguinea Sí No Quien: Comentarios: Colesterolalto Sí No Quien: Comentarios: Anemia Sí No Quien: Comentarios: EnfermedaddlHigado/RiñonSí No Quien: Comentarios: Diabetesantes50) Sí No Quien: Comentarios: Epilepsia/Convulsiones Sí No Quien: Comentarios: Alcohol/Abusodedrogas Sí No Quien: Comentarios: Enfermedadesmentales/depresion Sí No Quien: Comentarios: Retrasomental Sí No Quien: Comentarios: ProblemasinmunologicósSí No Quien: Comentarios: VIH/SIDA Sí No Quien: Comentarios: Cancer Sí No Quien: Comentarios: ProblemasGastrointestinalesSí No Quien: Comentarios: Revised:2/1/15 Page 2 of 3
3 HISTORIAPASADA ensucaso, Suhijo/atieneoaél/ellaalgunavez: Infeccionesdeoídofrecuentes/pérdidadelaaudición Sí No Explique: Problemasconlosojosolavisión Sí No Explique: Elasma,labronquitis,laneumonía Sí No Explique: CualquierproblemadecorazónosoplocardíacoSí No Explique: Laanemiaounproblemadesangrado Sí No Explique: Frecuentedolorabdominal/estreñimiento Sí No Explique: InfeccióndeVejigaoelRiñión Sí No Explique: Mojarlacamadespuésde5añosdeedad) Sí No Explique: F) Hacomenzadosuperiodomenstrual? Sí No Explique: Ningúnproblemacrónicaorecurrentedelapiel Sí No Explique: Doloresdecabezafrecuentes Sí No Explique: Convulsionesoproblemasneurológogicos Sí No Explique: Diabetes Sí No Explique: Problemasdelatiroidesuotroendocrinos?Sí No Explique: UsodeAlcohol/Drogas Sí No Explique: Lesionesenlacabeza,conmocióncerebral,opérdidadelaconciencia: Sí No Explique: Cualquierotroproblemasignificativo? Sí No Explique: EDUCACIÓN: Aquéescuelaasistesuhijo/a? Quégradodenivel? Suhijo/arecibeeducaciónespecial? Sí No Encasoafirmativo,porfavorexplique: Revised:2/1/15 Page 3 of 3
4 Patient Consent Form for Electronic Exchange of Individual Health Information HealtHIE Nevada is a non-profit organization dedicated to connecting the healthcare community to share information electronically and securely to improve the quality of healthcare services. To learn more about the Health Information Exchange HIE), read the Patient Information brochure. You can ask the doctor that gave you this form for it, or go to the website Details about patient information in HealtHIE Nevada and the consent process: 1. How your information will be used and who can access it: When you provide consent, only HealtHIE Nevada participants such as doctors, hospitals, laboratories, radiology centers, and pharmacies), will have access to your health information. It can only be used to: Provide you with medical treatment and related services. Evaluate and improve the quality of medical care provided to all patients, using de-identified health information. 2. Types of information included and where it comes from: The information about you comes from organizations that have provided you with medical care, and are HealtHIE Nevada participants. These may include hospitals, physicians, pharmacies, clinical laboratories, and other healthcare organizations. Your health records may include a history of illnesses or injuries you have had like diabetes or a broken bone), test results like X-rays or blood tests), and lists of medications your doctor has prescribed. This may include information created before the date of this Consent Form. This information may relate to sensitive health conditions, including but not limited to: Alcohol or drug use problems HIV/AIDS Birth control and abortion family planning) Genetic inherited) diseases or tests Mental health conditions Sexually transmitted diseases 3. Improper Access or Disclosure of your Information: Electronic information about you may be disclosed by a participating doctor to others only to the extent permitted by Nevada State Law. If at any time you suspect that someone who should not have seen or received information about you has done so, you should notify your doctor. 4. Effective Period: Your consent becomes effective upon signing this form and will remain in effect until the day you revoke it or HealtHIE Nevada ceases to conduct business. 5. Revoking your consent: At any time, you may revoke your consent by signing a new consent form and giving it to your doctor. These forms are available at your doctor s office, or by calling Changes to your consent status may take hours to become active in the system. Note: Organizations that access your health information through HealtHIE Nevada while your consent is in effect may copy or include your information into their own medical records. Even if you later decide to withdraw your consent, they are not required to return it or remove it from their records. 6. How your information is protected: Federal and State laws and regulations protect your medical information. HIPAA, the Healthcare Insurance Portability and Accountability Act of 1996, is the federal law that protects your medical records and limits who can look at and receive your health information, including electronic health information. HIPAA s protections were further strengthened by another federal law, the HITECH Act of 2009, which may impose severe financial fines on anyone who violates your medical privacy rights. All health information made available on the HIE, including your medical information, is encrypted to federal standards and is accessible only as allowed by Nevada State law NRS ). In addition, your doctor must provide you with a Notice of Privacy Practices, which describes how he or she uses and protects your medical information. Copy of Form: You are entitled to receive a copy of this Consent Form after you sign it.
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