Dartmouth-Hitchcock Medical CenterOne Medical Center DriveLebanon, NH 03756-0001

Phone (603) 629-8355CHaDKids.org

Connective Tissue Disorders Patient Intake

In the column on the right side of the table, please add your comments to help us better understand your health history. Once you have filled in your history information, please mail the form to us in the enclosed envelope.

Patient Name:Date of Birth:

Developmental History: Were you a late walker? Were you a late talker? Did you have any trouble learning in

school?

Obstetric History (if applicable): How many pregnancies have you had? List modes of delivery (vaginal, C-

section) Please list your children’s names,

genders, ages, and any medical problems.

During pregnancy, did you have any of the following symptoms:

Premature labor Delivery before 36 weeks gestation Postpartum hemorrhage/bleeding

requiring transfusion

Family history: A complete family history will be obtained

during your visit. If possible, gather information about your

immediate and extended family members including any heritable disorders, unique or unusual medical conditions, and the cause and age of death for any closely related deceased family members.

Surgical History: Please list any surgeries that you have

had, including even minor childhood procedures such as ear tubes, tonsillectomy, dental extractions, etc. Include approximate date or age at the time of the procedure.

Dartmouth-Hitchcock Clinic | Mary Hitchcock Memorial Hospital | Dartmouth Medical School

Social History: With whom do you live at this time? If applicable, what is your line of work?

Symptoms:Please provide us with information about any symptoms that you currently experience or have experienced in the past:

Eye symptoms, such as: Near-/Far-sighted Astigmatism Cataracts Glaucoma Ptosis Eye movement disorders

Ear symptoms, such as: Hearing loss (including age of onset)

Dental symptoms, such as: Receding gums Early/Unexplained dental loss/cracking Deficient enamel Dental crowding requiring extractions High/Narrow palate required expansion Missing secondary teeth Excessive bleeding with home dental

care or professional care TMJ symptoms (jaw popping, getting

stuck)Swallowing/Upper GI symptoms, such as:

Swallowing dysfunction (food pocketing, choking)

Reflux Unusual changes in voice quality

Heart symptoms, such as: Congenital heart defect Heart murmur Irregular heart beat Have you had an echocardiogram (heart

ultrasound), if yes, please note when, where, and any relevant findings

Breathing/Respiratory symptoms, such as:

Shortness of breath Asthma Pneumothoraces (collapsed lung) Sleep-disordered breathing Apnea requiring mechanical intervention

Lower GI symptoms, such as: Irritable bowel symptoms

Diarrhea Constipation Abdominal bloating/distention Abdominal pain Discomfort with eating Slow motility

Genitourinary symptoms, such as: Kidney problems Urinary problems (increased urgency,

frequency, leakage) Collapse/Prolapse of internal female

organsMusculoskeletal symptoms, such as:

Hyperextensible/Loose joints Spontaneous joint dislocations Subluxing joints (popping) Fractured bones Osteoarthritis (including location(s), age

of onset) Osteopenia (thinning of bones) (including

location(s) and age of onset) Scoliosis (curve of the spine) Chest wall deformity/asymmetry (pectus

deformities, aka “funnel chest” or “pigeon chest”

Skin symptoms, such as: Slow healing skin Separation of stitches Unusual scarring (widened or darkened

scars) Stretch marks, including location and age

of onset (associated with weight gain/loss, rapid growth, pregnancy)

Raynaud’s phenomenon Birth marks (lighter, darker, red patches)

Neurologic symptoms, such as: Seizures Headaches Nerve pain (numbness, tingling, burning,

shooting pains) Weakness

Endocrine symptoms, such as: Growth problems Diabetes Thyroid disorder Other hormone conditions

Psychiatric symptoms, such as: Depression Anxiety

Hematologic/Bleeding symptoms, such as:

Easy bruising Heavy periods Excessive bleeding: after surgery or

childbirth, with routine dental care, etc.

General symptoms, such as: Sleep disorder (trouble falling asleep,

staying asleep) Dizziness/Light-headedness upon

standing POTS Pain symptoms, including:

o Age of onset (even childhood “growing pains”)

o Location(s) of pain symptomso Any precipitating factors (injury,

accident, etc.)o Current management and

effectivenessOther information: