Patient Registration Form

Main Office
3124 Blue Ridge Road, Suite 102
Raleigh, NC 27612
Office Number: (919) 782‐0021

Brier Creek Office
10208 Cerny Street, Suite 104
Raleigh, NC 27617
Office Number: (919) 226‐0662

Patient's Last Name:

First Name:

Middle Initial:

MOTHER/LEGAL GUARDIAN

Name:

DOB:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cellphone:

Email:

Marital Status:

Single Married Divorced Widowed

FATHER/LEGAL GUARDIAN

Name:

DOB:

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cellphone:

Email:

Marital Status:

Single Married Divorced Widowed

Who is the primary caregiver?

Both Father Mother

Other (Please Explain):

If applicable, who has primary custody?

Both Father Mother

*(Please provide legal documentation for any alternative custody arrangements.)

EMERGENCY CONTACT (Other Than Parent)

Name:

Relationship:

Home Phone:

Cell Phone:

INSURANCE INFORMATION

Primary Insurance Company Name:

Insured’s ID Number:

Group Plan Number:

Insured (Policy Holder) First and Last Name:

ADDITIONAL INFORMATION

Race (select one):

American Indian/Alaskan Native Asian Black/African American Native Hawaiian Other Pacific Islander White More than 1 Race Declines to Respond

Ethnicity: (select one):

Hispanic or Latino Not Hispanic or Latino Declines to Respond

Preferred Language:

Pharmacy Name:

Pharmacy Address:

Pharmacy Phone Number:

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.

SIGNED (Patient, or parent if under 18 years of age.)

Date

Initial History Questionnaire

Child’s Full Name:

Preferred Name:

Form Completed by:

Relationship:

Today’s date:

DOB:

Sex

Male Female

Chart#:

SOCIAL HISTORY

Please list those living in the child’s home:

Name:

Relationship:

Birth Date:

Job or School:

Health Problems:

Add new information

Biological Parents:

Married Divorced Single Seperated Remarried

If both parents are not living together, who has custody?

Are there any siblings not listed above?

Yes No

Does your child go to daycare?

Yes No

If Yes, where:

Does your child go to school?

Yes No

If Yes, where:

Does anyone in your family smoke (even outside)?

Yes No

If Yes, who?:

Does your family have any pets?:

Yes No

If Yes, what kind:

Do you have smoke alarms in your house?

Yes No

Does your family routinely use seatbelts/carseats?

Yes No

BIRTH HISTORY of your child

Born:

On Time Late Premature

If premature, how early? gestational age (please indicate below) weeks:

At what hospital?

Birth weight: (lbs./ozs)

Did mom have any problems with pregnancy?

Yes No

If Yes, what type of problems:

Was your baby born by Cesarean section?

Yes No

If Yes, why:

Did your baby have any problems after birth?

Yes No

If Yes, what type(s):

Did baby stay in the hospital after mom went home?

Yes No

If Yes, why:

PAST MEDICAL HISTORY

Has your child had any surgery?

Yes No

If Yes, when and why:

Has your child ever been hospitalized?

Yes No

If Yes, when and why:

Does your child have any chronic or serious medical conditions?

Yes No

If Yes, what type(s):

Has your child had any serious accidents or injuries?

Yes No

If Yes, what type(s):

Does your child have any developmental problems?

Yes No

If Yes, what type(s):

Is your child allergic to any medications?

Yes No

If Yes, name of medicine and what type of reaction(s):

Did your child miss or skip any vaccines?

Yes No

If Yes, which ones:

Does your child take any medications on a regular basis?

Yes No

If Yes, what medicine and dosage:

Any over the counter medications on a regular basis?

Yes No

If Yes, what medicine and dosage:

Where did you hear about our practice?

Extra Comments:

FAMILY HISTORY

Any family members (parents, siblings, grandparents, aunts or uncles only) have these?

Active Smoker

Yes No

Relation/Type Problem

Allergies

Yes No

Relation/Type Problem

Anemia/Blood

Yes No

Relation/Type Problem

Asthma

Yes No

Relation/Type Problem

Birth Defect

Yes No

Relation/Type Problem

Bone/Joint probs

Yes No

Relation/Type Problem

Cancer

Yes No

Relation/Type Problem

Deafness

Yes No

Relation/Type Problem

Diabetes

Yes No

Relation/Type Problem

Drug abuse

Yes No

Relation/Type Problem

Eye problems

Yes No

Relation/Type Problem

Genetic Defect

Yes No

Relation/Type Problem

Heart Disease

Yes No

Relation/Type Problem

High Blood-Pressure

Yes No

Relation/Type

High Cholesterol

Yes No

Relation/Type

HIV/AIDS

Yes No

Relation/Type

Immune Problems

Yes No

Relation/Type

Kidney disease

Yes No

Relation/Type

Learning Problems

Yes No

Relation/Type

Liver disease

Yes No

Relation/Type

Lung disease

Yes No

Relation/Type

Mental Illness

Yes No

Relation/Type

Rheumatic Fever

Yes No

Relation/Type

Seizures

Yes No

Relation/Type

Thyroid disease

Yes No

Relation/Type

Tuberculosis

Yes No

Relation/Type

REVIEW OF SYSTEMS

Has your child had any problems with or do you have concerns with any of the following:

Abdominal Pain

Yes No

Comments on “Yes”

Allergy

Yes No

Comments on “Yes”

Anemia

Yes No

Comments on “Yes”

Asthma/wheezing

Yes No

Comment on "Yes"

Attention problems

Yes No

Comments on “Yes”

Bedwetting/soiling

Yes No

Comments on “Yes”

Bladder/kidney probs

Yes No

Comments on “Yes”

Bleeding problems

Yes No

Comments on “Yes”

Broken Bones

Yes No

Comments on “Yes”

Cancer/Leukemia

Yes No

Comments on “Yes”

Cerebral Palsy

Yes No

Comments on “Yes”

Chickenpox

Yes No

Comments on “Yes”

Constipation

Yes No

Comments on “Yes”

Cystic Fibrosis

Yes No

Comments on “Yes”

Dental problems

Yes No

Comments on “Yes”

Developmental probs

Yes No

Comments on “Yes”

Diabetes

Yes No

Comments on “Yes”

Emotional/Behavioral

Yes No

Comments on “Yes”

Genetic Disorders

Yes No

Comments on “Yes”

Hearing problems

Yes No

Comments on “Yes”

Heart, murmurs

Yes No

Comments on “Yes”

High blood pressure

Yes No

Comments on “Yes”

Illicit drug use

Yes No

Comments on “Yes”

Joint Pain/swelling

Yes No

Comments on “Yes”

Learning problems

Yes No

Comments on “Yes”

Liver problems

Yes No

Comments on “Yes”

Many ear infections

Yes No

Comments on “Yes”

Many headaches

Yes No

Comments on “Yes”

Many sore throats

Yes No

Comments on “Yes”

Menstrual problems

Yes No

Comments on “Yes”

Nasal problems

Yes No

Comments on “Yes”

Pneumonia

Yes No

Comments on “Yes”

Seizures

Yes No

Comments on “Yes”

Skin problems

Yes No

Comments on “Yes”

Sleep problems

Yes No

Comments on “Yes”

Speech/Language

Yes No

Comments on “Yes”

Thyroid problems

Yes No

Comments on “Yes”

Vision or Eyes

Yes No

Comments on “Yes”

Any Other Concerns/Extra Comments:

Thank you for your time filling out this form. Please sign below stating to the best of your knowledge the above information is correct.

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 parent/guardian

Date:

I have reviewed the above information with the parent/guardian.

Provider Signature:

Date:

Your information will be encrypted.