New Patient Packet

Patient Information

First Name

Last Name

Date of Birth

Sex

SSN

Race

Ethnicity

MOTHER/LEGAL GUARDIAN

FATHER/LEGAL GUARDIAN

Name

Date of Birth

Primary Phone #

Date of Birth

Primary Phone #

Address

If applicable, who has primary custody? (Court documentation must be provided before a child is seen for custody related matters/foster/dss/adoptions/temporary or permanent placement with a guardian.)

Mother Father

Emergency Contact (Other than Parent)

Name

Phone #

Please list all persons who may call for medical advice or bring your child to the office for treatment. These individuals must show ID at the time of the visit. If someone other than these persons bring your child in, we will have to contact you for a one time verbal over the phone for your child to be seen. If we are unable to reach you, we will only see your child in case of an emergency.

Add Person

Insurance Information

Primary Insurance

Policy #

Policy Holder Name

DOB

Relationship to Patient

Effective Date

Primary Insurance

Policy #

Policy Holder Name

DOB

Relationship to Patient

Effective Date

As a courtesy, Seashore Pediatrics will file your insurance provided but cannot guarantee payment. I understand that I am financially responsible for copays/deductibles/etc. for services rendered when charges incur. I hereby authorize Seashore Pediatrics to release all medical information required by my insurance company to file claims for medical benefits. I authorize payment of all applicable benefits directly to Seashore Pediatrics.

Additional Information

Pharmacy Name

Phone #

Acknowledgement of Notice of Privacy Policy

I acknowledge receipt of the privacy rights with detailed information regarding how Seashore Pediatrics may use and disclose my child's protected health information. I authorize Seashore Pediatrics to release my child's protected health information when contacting me by phone, mail or email I provided on my child's registration form with appointment reminders, test results, account balance information and any other health related information pertaining to my child. This authorization will remain in effect unless revoked in writing.

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

Date

Initial History

Patient's Name

Sex

Male Female

DOB

Chart#

Form completed by

Relation to patient

Date

Family

Are mother and father

married separated / divorced?

If separated/divorced, what is the patient's custody status?

If one or both parents are not living in tire home, how often does child see that parent(s)?

Are there siblings living away from home?

Yes No

If yes, give name, age and where they live

List all family members living in the patient's home

Add Family Member

Current Medical History

Is your child having any medical problems?

Yes No

Are immunizations up to date?

Yes No

Do you consider your child to be in good health?

Yes No

Drug Allergies?

Yes No

Current Medications

Review of Systems and Past Medical History

Does the patient now have or has ever had any of the following:

1. a serious medical problem?

Yes No

Explain

2. been hospitalized or had surgery?

Yes No

Explain

4. chickenpox?

Yes No

When?

Explain

5. allergies, asthma, bronchitis, respiratory infections?

Yes No

Explain

6. repeated ear infections, tubes, difficulty with hearing?

Yes No

Explain

7. problems with eyes or vision?

Yes No

Explain

8. heart problems or a heart murmur?

Yes No

Explain

9. anemia, bleeding problems or blood transfusion?

Yes No

Explain

10. abdominal pain, constipation requiring doctor visits?

Yes No

Explain

11. recurrent vomiting, recurrent diarrhea, blood in stools?

Yes No

Explain

12. bladder or kidney infections, bed-wetting after 5 yrs.?

Yes No

Explain

13. recurrent skin problems (acne, eczema, etc)?

Yes No

Explain

14. headaches, convulsions, other neurologic problems?

Yes No

Explain

15. diabetes, thyroid or other endocrine problems?

Yes No

Explain

16.Ifpatient is female, has she started her menstrual periods?

Yes No

Explain

If yes, is she having any problems?

Yes No

Explain

History Update (date /initial) Changes in history noted in chart on day of visit.

Development

Are you concerned about the patient's...

1. physical development?

Yes No

Explain

2. mental or emotional development?

Yes No

Explain

3. learning ability?

Yes No

Explain

4. attention span or activity level?

Yes No

Explain

If in school, has the patient had...

1. tutoring outside of the classroom?

Yes No

Explain

2. placement in a special or resource class?

Yes No

Explain

3. to repeat a grade?

Yes No

Explain

4. educational or psychological testing?

Yes No

Explain

5. behavioral problems?

Yes No

Explain

Maternal and Newborn History

Pregnancy Check if the mother had any of the following problems:

excessive wt. gain

urinary infections

excessive swelling

toxemia

rubella

venereal disease

other

none

Did the mother smoke, use recreational drugs or alcohol?

Yes No

Birth

Birth Weight

Length

Apgar

Was baby born at

early term late

If early, how many weeks gestation

Was labor difficult or prolonged?

Yes No

Was delivery difficult or complicated?

Yes No

Newborn Check if the patient had any of the following problems:

For feeding problems

Breast

Formula

Details

Family History

If a family member has or has had any of the following problems, check the appropriate box and list the family member: M-Mother F-Father S-Sibling GM-Grandmother GF-Grandfather A-Aunt U-Uncle

1. Deafness

11. Immunity problems/HIV

21. Stomach/GI

2. Allergies

12. High cholesterol

22. Cancer

3. Drug allergies

13. High blood pressure before 50 yrs

23. Epilepsy or convulsions

4. Asthma

14. Heart attack/stroke before 50 yrs

24. Hereditary problems

5. Eczema

15. Other heart problems

25. Learning prob./Attent. span

6. Respiratory infections

16. Anemia/Blood disorders

26. Emotional/Behavioral

7. Eye or visual problems

17. Diabetes before 50 yrs

27. Mental illness

8. Ear infections/tubes

18. Thyroid or other endocrine prob.

28. Mental retardation

9. Tuberculosis

19. Obesity

29. Drug/Alcohol abuse

10. Liver disease

20. Bladder/Kidney

30. Other

Provider Comments

History Reviewed by

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