Pediatric Intake Form

Our practice is dedicated to providing the best possible care for your child. In order for us to serve you better, please take a few minutes to answer the following questions. Your answers will be kept strictly confidential as a part of your child's medical record. Ongoing evaluations of our care may involve chart reviews by qualified persons, but neither your name nor your child's name will ever appear in any reports.

Childs Name

Parents Name

Relationship to Child

Date

How many times have you moved in the last year?

Besides you, does anyone else take care of this child?

Yes No

If yes, who?

Has child received healthcare elsewhere?

Yes No

Does the child have any allergies to any medications?

Yes No

If yes, what?

Is your child up to date with all Immunizations?

Yes No

If no, which ones are delayed

Has the child ever been hospitalized?

Yes No

When?

Where?

Why?

How would you rate this child's health in general?

Excellent Good Fair Poor

Do you have any concerns about your child?

How old are you?

Are you

Single Married Separated Divorced Other

What is the highest grade you completed?

FAMILY MEDICAL HISTORY

Does the child's mother, father or grandparents have any of the following, if yes, who?

High Blood Pressure

Yes No

Diabetes

Yes No

Lung Problems (asthma)

Yes No

Heart Problems

Yes No

Miscarriages

Yes No

Learning Problems

Yes No

Nerve Problems

Yes No

Mental Illness

Yes No

Drinking Problems

Yes No

Drug Problems

Yes No

FAMILY SAFETY

Does your child know how to cross the street?

Yes No

Does your child know what to do if approached by a stranger?

Yes No

How often does your child use a seat belt (car seat)?

Never Sometimes Always

Does your child ride a bicycle or skate?

Yes No

If yes, how often does he/she use a helmet?

Never Sometimes Always

In the past year, have you ever felt threatened in your own home?

Yes No

In the past year, has your partner or other family member pushed you, punched you, hit you or threatened to hurt you?

Yes No

What kind of guns are in your home?

Handguns Shotguns Rifle Other None

If Other, Please specify:

If you have a gun at home, is it locked up?

Yes No

Does anyone in your household smoke?

Yes No

Do you currently smoke cigarettes

Yes No

Do you currently smoke cigarettes

Do you have a smoke alarm and fire extinguisher?

Yes No

Does your child know about pool rules?

Yes No

Including NEVER to swim without an adult present?

Yes no

Do you encourage your child to wear sunscreen?

Yes No

Do you encourage your child to do physical activities or play sports?

Yes No

How

How many hours does your child spend using television, video games and/or computers on an average day?

What does your family do together for fun?

How strong are your family's religious beliefs or practices?

Very Strong Moderately Strong Not Strong

How often do you read bedtime stories to your child?

Frequently Often Occasionally Rarely Never

How many times per week do you eat "take-out" or eat in a restaurant?

What type of milk do you usually serve?

What type of fat do you use most often in cooking

WHEN YOU WERE A CHILD

Did either parent have a drug or alcohol problem?

Yes No

Were you raised part or all of the time by foster parents or relatives (other than your parents)?

Yes No

How often did your parents ground you or put in time out?

Frequently Often Occasionally Rarely Never

How often were you hit, punched or kicked by a family member?

Frequently Often Occasionally Rarely Never

Did you feel you were physically abused?

Yes No

Do you feel you were neglected?

Yes No

Do you feel you were hurt in a sexual way?

Yes No

Did your parents ever hurt you when they were out of control?

Yes No

Are you ever afraid you might lose control and hurt your child?

Yes No

How often in the last week have you felt depressed?

0 days 1-2 days 3-4 days 5-7 days

In the past year, have you had two weeks or more during which you felt sad, blue or depressed or lost pleasure in things that you usually card about or enjoyed?

Yes No

Have you had two or more years in your life when you felt depressed or sad most days, even if you felt OK sometimes?

Yes No

Do you have dependable support when you need help?

Yes No

TB/CHOLESTROL RISK ASSESSMENT

Has your child been in contact with persons who have tuberculosis?

Yes No

Is anyone of your family member who live in your household a recent immigrant from another country to the U.S. or has anyone traveled to another country for more than a month?

Yes No

Is anyone in the household infected with HIV or been in jail during the last 5 years?

Yes No

Has your child ever had a positive PPD or tuberculosis test?

Yes No

Does either of the parent have a cholesterol > 240?

Yes No

Has any member of your family had a heart attack or stroke before age 55?

Yes No

DRINKING AND DRUGS

In the past year have you had a drinking problem?

Yes No

Have you tried to cut down on alcohol in the past year?

Yes No

Have you ever had a drug problem?

Yes No

Have you used any drugs in the last 24 hours?

Yes No

If yes, which one

Cocaine

Heroin

Methadone

Speed

Marijuana

Other

If Other, Please specify

Are you in a drug or alcohol recovery program now?

Yes No

If yes, which one(s)

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.

Signature of Parent / Guardian

Date

Patient Consent

Name of Patient

Patient's Date of Birth

I hereby authorize (when I am unavailable to give consent) to the following individual(s)

Add Additional Person

to consent to any and all medical care and attention for this child which is deemed necessary and appropriate by a healthcare provider licensed in the State of Texas. This consent includes, but is not limited to, medical and surgical intervention and elective as well as emergency care. This delegation shall be valid until I withdraw the delegation of consent in writing.

Signature or Parent / Guardian

Date

Your information will be encrypted.