Female history pre-registration form

Parent/guardian first name

Parent/guardian last name

Parent/legal guardian phone number

Parent/legal guardian email

Parent/legal guardian street address

Parent/legal guardian city

Parent/legal guardian state

Parent/legal guardian zip

Patient first name

Patient last name

Patient date of birth

Who referred you to see the relative energy deficiency in sport (REDs) clinic form at Children’s Wisconsin? Pediatrician/Primary Care Provider School Coach Athletic Trainer

Previous patient of ... ? April Benoit, APNP Dr. Fehr Dr. Hornbeck Dr. Walter Dr. Lehman Children's Wisconsin orthopedic surgeon Other

If other, please specify

Describe the injury or problem that brings you to relative energy deficiency in sport (REDs) clinic.

Any recent X-Ray/MRI/CT/labs related to this injury/problem (if any)

Please list all supplements and regular medication (prescription and over-the-counter) and dosage you are currently taking

Please list any surgeries you have had

Please list any major health conditions

Do you have a history of stress fractures? Yes No

If yes, please explain

Have any of your injuries kept you out of your activities? Yes No

Please list any hospitalizations you have had

Orthopedic problems (bone or joint injury/surgery)? WHO

Osteoporosis? WHO

Heart disease? WHO

High blood pressure? WHO

Anesthesia complications? WHO

Cancer? WHO

Stroke? WHO

Diabetes? WHO

Blood problems? WHO

Nerve problems? WHO

Rheumatologic conditions (i.e: rheumatoid arthritis)? WHO

Autoimmune conditions (i.e: lupus)? WHO

Disordered eating? WHO

If other, please specify

None

Who lives in your household?

Parent relationship status Single Married Divorced

Smoking exposure at home? Yes No

School

Grade

Sports (List primary/current first)

Training load (How often do you practice per week and at what intensity)?

Do you participate in any extra training outside of sport practices? Yes No

Do you worry about missing a workout? Yes No

Anxiety? Yes No

Bipolar disorder? Yes No

Depression? Yes No

Sleep problems? Yes No

If yes, specify

Other psychiatric disorder? Yes No

If yes, specify

Have you ever worked with or are you currently seeing a therapist/psychologist/counselor/etc? Yes No

If yes, who?

Do you currently have any major stressors in your life? Yes No

If yes, how do you cope?

Constitution Fever Chills Weight change Fatigue Unusual sweating Weakness

Skin Rash Itching

HENT Headaches Hearing loss Ear ringing Ear pain Ear discharge Nosebleeds Congestion Sore throat

Eyes Blurred vision Double vision Light sensitivity Eye pain Eye discharge Eye redness

Cardiovascular Chest pain Palpitations Leg swelling

Respiratory Cough Shortness of breath Wheezing

Gastrointestinal Heartburn Nausea Vomiting Abdominal pain Diarrhea Constipation Blood in stool

Genitourinary Painful urination Urgency Increased frequency Blood in urine Kidney disease

Heme/Allergies Easy bruising/bleeding Environmental allergies

Neurological Dizziness Tingling Tremors Sensory change Speech change Loss of consciousness

Psychiatric Depression Nervous/anxious Insomnia Memory loss

Reproductive Menstrual problems STI Pregnancy

Endocrine Immune system problems Thyroid problems Growth problems

Do you worry about your weight? Yes No

Has your diet and hydration routine changed recently? Yes No

If yes, how so?

Were changes made to your diet and hydration made due to your sport? Yes No

Has anyone suggested a change to your diet and/or hydration routine recently? Yes No

Have you been avoiding certain foods recently? Yes No

If so, what and why?

Age at first period?

Start of last menstrual cycle?

How long between periods?

Average length of period?

How many periods have you had this year?

In this section

Sports Medicine Program

Relative energy deficiency in sport form

Parent/guardian contact information - If you are a patient 18 years or older, please also fill out this information in place of parent/guardian.

Patient Information

Referral

Injury information

Medications

Family history: Does anyone in your family have any of the following problems? Please check the box and list who (Siblings, parents, and/or grandparents).

Social history

Mental health history: Has the patient ever been diagnosed with the following?

Nutrition

Menstrual history