Patient Form

Patient Registration

Child's name:

Sex:

Date of Birth:

Telephone:

Address:

City:

Zip:

Mother's name:

Date of Birth:

Address:

City:

Zip:

Father's name:

Date of Birth:

Address:

City:

Zip:

Emergency contact:

Phone number:

List any sisters and brothers and date of birth

Add another

Insurance for child:

ID number an group:

DISCLAIMER: 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: (if > 18yrs)

Signature of Parent or Guardian:

Relationship to child:

Date:

Initial History Questionnaire

Form Completed By:

Date Completed:

Name:

ID Number:

Birth Date:

Household

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

Add another

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?

If early, how many weeks' gestation?

Did mother have any illness or problem with her pregnancy?

Yes No

If yes, please explain:

During pregnancy, did mother

Smoke?

Yes No

Drink alcohol?

Yes No

Use drugs or medications:

Yes No

What:

When:

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:

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?

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

Explain:

(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:

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