New Patient Form

Patient Registration

Date:

Cell Phone Parent 1:

Cell Phone Parent 2:

Last Name:

First Name:

MI:

Birth Date:

Age:

Street Address:

City:

State:

Zip:

Home Phone:

Email Address

Gender:

Male Female

Do other family members receive care in this office?

Yes No

If yes, name(s):

Name of Parent/Guardian #1:

Relationship to Patient:

Street Address (if different)

City:

State:

Zip:

Birth Date:

Email Address

Home Phone (if different):

Occupation:

Employed by:

Work Phone:

Work Street Address:

City:

State:

Zip:

Name of Parent/Guardian #2:

Relationship to Patient:

Street Address (if different)

City:

State:

Zip:

Birth Date:

Email Address

Home Phone (if different):

Occupation:

Employed by:

Work Phone:

Work Street Address:

City:

State:

Zip:

WHO TO CONTACT IF WE CAN'T REACH PARENT/GUARDIAN IN AN EMERGENCY?

Name:

Relationship to Patient:

Home Phone:

Street Address:

City:

State:

Zip:

INSURANCE INFORMATION

Name of Primary Insurance Carrier:

Name of Policy Holder:

Insurance Identification Number:

Group Number:

Street Address:

City:

State:

Zip:

Name of Secondary Insurance Carrier:

Name of Policy Holder:

Insurance Identification Number:

Group Number:

Street Address:

City:

State:

Zip:

The guarantor is responsible for all fees. Fees are due at the time of service.
Please read and sign the following Authorization and Assignment.

Insurance Authorization & Assignment

I hereby authorize Ofelia B. Ayuste, M.D.S.C. to furnish information to my insurance company carrier concerning my child or children's illness or treatment. I also hereby assign the Doctor all outstanding payments for medical services rendered to my dependent(s). I UNDERSTAND I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY MY INSURANCE.

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

Insured/Parent's Signature:

Family History

Have any family members had the following:

Deafness

Yes No

Who:

Comments:

Nasal allergies

Yes No

Who:

Comments:

Asthma

Yes No

Who:

Comments:

Tuberculosis

Yes No

Who:

Comments:

Heart disease (before 50 years old)

Yes No

Who:

Comments:

High blood pressure (before 50 years old)

Yes No

Who:

Comments:

High cholesterol

Yes No

Who:

Comments:

Anemia

Yes No

Who:

Comments:

Bleeding disorder

Yes No

Who:

Comments:

Liver disease

Yes No

Who:

Comments:

Kidney disease

Yes No

Who:

Comments:

Diabetes (before 50 years old)

Yes No

Who:

Comments:

Bed-wetting (after 10 years old)

Yes No

Who:

Comments:

Epilepsy or convulsions

Yes No

Who:

Comments:

Alcohol abuse

Yes No

Who:

Comments:

Drug abuse

Yes No

Who:

Comments:

Mental illness

Yes No

Who:

Comments:

Mental retardation

Yes No

Who:

Comments:

Immune problems, HIV, or AIDS

Yes No

Who:

Comments:

Additional family history

Past History

Does your child have, or has he/she ever had:

Chickenpox

Yes No

When:

Frequent ear infections

Yes No

Explain:

Problems with ears or hearing

Yes No

Explain:

Nasal allergies

Yes No

Explain:

Problems with eyes or vision

Yes No

Explain:

Asthma, bronchitis, bronchiolitis, or pneumonia

Yes No

Explain:

Any heart problem or heart murmur

Yes No

Explain:

Anemia or bleeding problem

Yes No

Explain:

Blood transfusion

Yes No

Explain:

Frequent abdominal pain

Yes No

Explain:

Constipation requiring doctor visits

Yes No

Explain:

Bladder or kidney infection

Yes No

Explain:

Bed-wetting (after 5 years old)

Yes No

Explain:

(For girls) Has she started her menstrual periods?

Yes No

When:

(For girls) Are there problems with her periods?

Yes No

Explain:

Any chronic or recurrent skin problem (acne, eczema, etc)

Yes No

Explain:

Frequent headaches

Yes No

Explain:

Convulsions or other neurologic problem

Yes No

Explain:

Diabetes

Yes No

Explain:

Thyroid or other endocrine problem

Yes No

Explain:

Any other significant problem

Yes No

Explain:

Use of alcohol or drugs

Yes No

Explain:

Initial History Questionnaire

Name:

ID NUMBER:

BIRTH DATE:

AGE:

Gender:

Male Female

FORM COMPLETED BY:

DATE COMPLETED:

Household

Please list all those living in the child's home.

Name:

Relationship to child:

Birth date:

Health problems:

Add new child

Are there siblings not listed? If so, please list their names and ages and where they live

If mother and father are not living together or if child does not live with parents, what is the child's custody status?

If one or both parents are not living in the home, how often does he/she see the parent/parents not in the home?

Birth History

Birth Weight:

Was the delivery

Vaginal? Cesarean?

If cesarean, why?

Was the baby born at term?

Early Late At Term

If early, how many weeks' gestation?

Did mother have any illness or problem with her pregnancy?

Yes No

Explain:

Did your baby have any problems right after birth?

Yes No

Explain:

Was initial feeding

Breast? Bottle?

Did your baby go home with mother from the hospital?

Yes No

Explain:

During pregnancy, did mother

Smoke

Yes No

Drink alcohol

Yes No

Use drugs or medications

Yes No

What:

When:

General

Do you consider your child to be in good health?

Yes No

Explain:

Does your child have any serious illness or medical condition?

Yes No

Explain:

Has your child had serious injuries or accidents?

Yes No

Explain:

Has your child had any surgery?

Yes No

Explain:

Has your child ever been hospitalized?

Yes No

Explain:

Is your child allergic to any medicines or drugs?

Yes No

Explain:

Development

Are you concerned about your child's physical development?

Yes No

Explain:

Are you concerned about your child's mental or emotional development?

Yes No

Explain:

Are you concerned about your child's attention span?

Yes No

Explain:

If your child is in school:

How is his/her behavior in school?

Has he/she failed or repeated a grade in school?

How is he/she doing in academic subjects?

Is he/she in special or resource classes?

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