Download Pediatric New Patient Information

Pediatric New Patient Information
Date: ___________________
Patient Information
Name: _____________________________ Date of Birth: ____________ Age: _____
Reason for Visit: _________________________________________________________
Sex: M / F Social Security #: ____________________
Home Phone #: ______________________
Home Address: __________________________________________________________
Who may we thank for referring you? _________________________________________
Family Information
Mother’s Name: _____________________ Father’s Name: ______________________
Date of Birth: _______________________ Date of Birth: _______________________
Home Phone #: ______________________ Home Phone #: ______________________
Work Phone #: ______________________ Work Phone #: ______________________
Parent’s Marital Status: Married ___ Single ___ Divorced ___ Widowed ___
Insurance Policy Holder’s Date of Birth: ______________________________________
List the ages of other children in the family: ___________________________________
Consent to Treat:
Being the parent or legal guardian of this child, I hereby authorize this office and its doctors to
examine and administer care to my son / daughter named _________________
as the examining/treating doctor deems necessary.
I understand and agree that I am personally responsible for payment of all fees charged by this
office for such care.
Parent’s Name: __________________________________ Date: __________________
Signature: ______________________________________ Witness: _______________
3 through 5 years History
Patient Name: ________________________________________ Date: __________________
HEALTH HISTORY
YES NO
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Has your child had asthma? ______________________________________________
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Does your child ever complain of back or neck pain? ___________________________
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Does your child ever complain of pains in the arms or legs? _____________________
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Does your child ever complain of headaches? _________________________________
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Has your child had any earaches? At what age did the first earache occur? _________
How frequently does your child have earaches? ______________________________
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Do your child’s earaches usually tend to occur in the same ear? RIGHT / LEFT / BOTH
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Is your child allergic to anything? ___________________________________________
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Are there any smokers in the child’s home? __________________________________
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Has your child had any other illnesses? ______________________________________
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Do you have any other concerns about your child’s health? ______________________
______________________________________________________________________
TRAUMA
YES NO
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Has your child ever fallen down stairs or fallen from any height? _________________
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Has your child ever fallen from a bicycle, skateboard, scooter, rollerblades, etc.? ____
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Has your child ever been in a car accident or near-miss? ________________________
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Has your child ever had a bone fracture or joint dislocation? ____________________
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Does your child ever bang his/her head repeatedly against a wall, bed, or other
object? _______________________________________________________________
NUTRITION
YES NO
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Do you have any concerns about your child’s diet? ____________________________
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Does your child have any food allergies? ____________________________________
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Does your child have any persistent or intermittent skin rashes? _________________
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Does your child eliminate stools every day? __________________________________
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Is your child receiving vitamin supplements? _________________________________
For how many months was your child breastfed? _____________________________________
What does your child usually eat for breakfast? ______________________________________
What does your child usually eat for lunch? __________________________________________
What does your child usually eat for dinner? _________________________________________
What does your child usually eat for snacks? _________________________________________
How much cow’s milk does your child drink each day? _________________________________
What is your child’s favorite food? _________________________________________________
What type of fast foods does your child like to eat? ___________________________________
PATIENT INTAKE FORM PEDIATRIC (3yo – 11yo)
Patient Name: ____________________________________
Date: _______________
1. Is today's problem caused by: □ Auto Accident
2. Indicate on the drawings below where you have pain/symptoms
3. How often do you experience your symptoms?
□ Constantly (76-100% of the time)
□ Occasionally (26-50% of the time)
□ Frequently (51-75% of the time)
□ Intermittently (1-25% of the time)
4. How would you describe the type of pain?
□ Sharp
□ Numb
□ Dull
□ Tingly
□ Diffuse
□ Sharp with motion
□ Achy
□ Shooting with motion
□ Burning
□ Stabbing with motion
□ Shooting
□ Electric like with motion
□ Stiff
□ Other:________________________________________
5. How are your symptoms changing with time?
□ Getting Worse
□ Staying the Same
□ Getting Better
6. Using a scale from 0-10 (10 being the worst), how would you rate your problem now?
0 1 2 3 4 5 6
7 8
9 10 (Please circle)
7. Who else have you seen for your problem?
□ Chiropractor
□ Neurologist
□ Primary Care Physician
□ ER physician
□ Orthopedist
□ Other:_____________
□ Massage Therapist □ Physical Therapist □ No one
8. How long have you had this problem? _________________
9. How do you think your problem began?
____________________________________________________________________________
10. Do you consider this problem to be severe?
□ Yes
□ Yes, at times
□ No
11. What is your: Height_________ Weight ____________ Date of Birth ______________
12. How would you rate your overall health?
□ Excellent
□ Very Good
□ Good
□ Fair
□ Poor
13. Indicate if you have any immediate family members with any of the following:
□ Rheumatoid Arthritis
□ Diabetes
□ Lupus
□ Heart Problems
□ Cancer
□ ALS
14. For each of the conditions listed below, place a check in the "past" column if you
have had the condition in the past. If you presently have a condition listed below, place a
check in the "present" column.
Past
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Present
Past Present
Past Present
□ Headaches
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□ High Blood Pressure
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□ Diabetes
□ Neck Pain
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□ Heart Attack
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□ Excessive Thirst
□ Upper Back Pain
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□ Chest Pains
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□ Frequent Urination
□ Mid Back Pain
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□ Stroke
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□ Smoking/Tobacco Use
□ Low Back Pain
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□ Angina
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□ Drug/Alcohol Dependence
□ Shoulder Pain
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□ Kidney Stones
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□ Allergies
□ Elbow/Upper Arm Pain
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□ Kidney Disorders
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□ Depression
□ Wrist Pain
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□ Bladder Infection
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□ Systemic Lupus
□ Hand Pain
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□ Painful Urination
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□ Epilepsy
□ Hip Pain
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□ Loss of Bladder Control □
□ Dermatitis/Eczema/Rash
□ Upper Leg Pain
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□ Prostate Problems
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□ HIV/AIDS
□ Knee Pain
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□ Abnormal Weight Gain/Loss
□ Ankle/Foot Pain
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□ Loss of Appetite
For Females Only
□ Jaw Pain
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□ Abdominal Pain
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□ Birth Control Pills
□ Joint Pain/Stiffness
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□ Ulcer
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□ Hormonal Replacement
□ Arthritis
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□ Hepatitis
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□ Pregnancy
□ Rheumatoid Arthritis
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□ Liver/Gall Bladder Disorder
□ Cancer
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□ General Fatigue
□ Tumor
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□ Muscular Incoordination
□ Asthma
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□ Visual Disturbances
□ Chronic Sinusitis
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□ Dizziness
□ Other:____________________________
15. List all surgical procedures you have had:
____________________________________________________________________________
16. Have you ever been hospitalized?
□ No □ Yes – if yes, why?
____________________________________________________________________________
17. Have you had significant past trauma? □ No
□ Yes – if yes, explain
____________________________________________________________________________
18. Anything else pertinent to your visit today? ___________________________________
Patient Signature___________________________________ Date: ____________________
EHR CERTIFICATION – PATIENT INFORMATION
Our electronic health records software requires the following information:
Name: ___________________________________________
Date: __________________
Date of Birth: ____________________________
Ethnicity: □ Hispanic or Latino
□ NOT Hispanic or Latino
Race: □ White □ Black/African American □ American Indian/Alaskan Native □ Asian
□ Native Hawaiian/Pacific Islander □ Two or More
Preferred Language: □ English
□ Spanish
□ Other: ________________
What is your preferred method of contact?
□ Home □ Cell □ Work
Phone Number: _______________________________
Smoking Status: □ Smoke every day □ Smoke some days □ Former smoker □ Never smoked
Prescribed Medications
Check here if NOT taking any prescribed medications □
Medication
# of refills Quantity
Strength
issued
of pills
(ex. 10mg)
Dose Form
(ex. capsule
or tablet)
MD’s
instructions:
(ex. 1/day)
Are you allergic to any medications? If so, please list each medication and symptom.
Check here if you do not have any allergies to medications □
Name of Medication
Symptom (ex. rash)
CONSENT FOR USE OR DISCLOSURE OF HEALTH INFORMATION
Our Privacy Pledge
We are very concerned with protecting your privacy. While the law requires us to give you a copy of our
privacy notice, please understand that we have, and always will, respect the privacy of your health
information.
There are several circumstances in which we may have to use or disclose your health care information.
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We may have to disclose your health information to another health care provider or a hospital if it is
necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.
We may have to disclose your health information and billing records to another party if they are
potentially responsible for the payment of your services.
We may need to use your health information within our practice for quality control or other
operational purposes.
Along with this consent form, you will be given a copy of our privacy notice that describes our privacy
policies in detail. You have the right to review that notice before you sign this consent form. We reserve
the right to change our privacy practices as described in that notice. If we make a change to our privacy
practices, we will notify you in writing when you come in for treatment or by mail.
Your right to limit uses or disclosures
You have the right to request that we do not disclose your health information to specific individuals,
companies, or organizations. If you would like to place any restrictions on the use or disclosure of your
health information, please let us know in writing. We are not required to agree to your restrictions.
However, if we agree with your restrictions, the restriction is binding on us.
Your right to revoke your authorization
You may revoke any of your authorizations at any time; however, your revocation must be in writing. We
will not be able to honor your revocation request if we have already released your health information
before we receive your request to revoke your authorization. If you were required to give your
authorization as a condition of obtaining insurance, the insurance company may have a right to your
health information if they decide to contest any of your claims.
I have read your consent policy and agree to its terms. I am also acknowledging that I have received a
copy of this consent form and a copy of your privacy notice (Notice of Privacy Practices for Protected
Health Information).
Printed Name
Authorized Provider Representative
Signature
Date
Date