New Patient Forms

Patient Information

The purpose of the questionnaire is to help us obtain information about your child and family to aid us in providing the best health care possible. Please answer all questions as they apply to your child. If a question does not apply or you prefer not to answer, leave it blank. If you do not understand a question, please please write don't understand so we can explain it further. This questionnaire will become part of your child’s health record, and as such will be strictly confidential.

Filled out by:

Relationship to Child:

Last Name:

First Name:

Middle Name:

DOB:

SSN:

Pronouns:

Biologic Sex:

Male Female

Patient Identies as:

Sexual Orientation:

Address:

City:

State:

Zip Code:

Phone:

Add another parent/guardian

Emergency Contact Name:

Relationship to Patient:

Phone:

Primary Insurance Company:

Policy ID #:

Group #:

Subscriber:

Responsible party for co-pays or other charges not covered by insurance:

Secondary Insurance Company:

Policy ID:

Group #:

Subscriber:

Responsible party for co-pays or other charges not covered by insurance:

Family Profile

1. Biologic Father’s Name

Age:

Education:

Employment:

Primary Residence?

Yes No

Percentage of time in this household:

2. Biologic Mother’s Name

Age:

Education:

Employment:

Primary Residence?

Yes No

Percentage of time in this household:

3. Stepfather's Name:

Age:

Education:

Employment:

4. Stepmother's Name:

Age:

Education:

Employment

5. Guardian's Name:

Age:

Education:

Employment:

Primary Residence?

Yes No

Percentage of time in this household:

6. Other Living Sutation:

7. Are parents divorced or separated?

Yes No

8. Siblings

Add another sibling

9. Other people living with your family:

Add another person

10. Years at present address

Type of dwelling

Owned/rented?

11. Does anyone in your home have persistent medical/mental health problems?

Yes No

12. Do you find it difficult to obtain medical care due to financial problems?

Yes No

13. Is it difficult to obtain food due to financial problems

Yes No

Consent For Release of Information

hereby authorize [Enter name of Authorized] to release information from my health record to South Royalton Health Center, PO Box 119, South Royalton, VT 05068, with no limitations placed on history of illness or diagnostic and therapeutic information, including any treatment for alcohol or drug abuse, psychiatric impairments or HIV test results/findings.

I hereby authorize South Royalton Health Center to release information from my health

record to [Enter Name Below] with no limitations placed on history of illness or diagnostic and therapeutic information, including any treatment for alcohol or drug abuse, psychiatric impairments or HIV test results/findings.

Patient Name:

DOB:

Address:

Information covering the period(s) of hospitalization from

Date of Admission:

to Date of Discharge:

OR

Information covering outpatient services from

Start date:

To:

Specific Information to be Released

Discharge Summary

Operative Report

History

Physical Exam

Other:

Reason for Release:

I understand that this consent can be revoked at any time. This authorization will be valid for one year unless otherwise specified.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient:

Date:

Relationship and/or authority if signed by person other than patient

Signature of Witness:

Date:

Note: Signature and Date must be later than the date of the information to be released. Signature of patient is to obtained unless patient is a minor or adjudged incompetent.

Health Questionnaire

Date:

Child’s Name:

Birth Date:

Filled out by:

Relationship to Child:

1. Did you have any problems during your pregnancy with this child?

Yes No

2. Were you on any medications during your pregnancy with this child?

Yes No

3. Was your child born more than two weeks early, or more than two weeks late?

Yes No

4.1. What was your child’s birth weight?

4.2. What was your child’s birth weight?

5. Did your child have any problems immediately following birth?

Yes No

6. How would you describe your child’s general health?

Excellent Good Fair Poor

7. In the past year, has your child missed more than seven days of school because of illness?

Yes No

8. Has your child ever been hospitalized? Had surgery?

Yes No

If yes, please list below:

Add hospitalization/surgery

9. Has your child ever been involved in a serious accident, or had an accidental toxic ingestion, or head injury?

Yes No

if yes, please describe

10. At what age did your child:

sit alone

dress him/herself

walk

tie his/her shoes

speak sentences

12. Does anyone in your household smoke/vape?

Yes No

13. Are there any unlocked firearms in your home?

Yes No

14. Is your water heater temperature set to 120 degrees or lower?

Yes No Don't know

15. Water Source:

Well Town Don't know

16. Does your water have fluoride in it?

Yes No Don't know

17. Does your child ride buckled and/or in a safe car seat?

Yes No

18. Do you and your children know what to do in case of an emergency?

Yes No

19. Do you have smoke alarms in your home?

Yes No Don't know

20. Do you have carbon monoxide detectors in your home?

Yes No Don't know

Family History

Have any of your child’s first-degree blood relatives (parents, grandparents, aunts, uncles, siblings, or cousins) had any of the following?

Add another relative

We thank you for your cooperation and time in helping us provide optimal care for your child.

Your information will be encrypted.