New Patient Form

Patient Name

Chart #

Date

Mother’s name

Age

Occupation

Father’s name

Age

Occupation

If adults in the household work outside the home, what child care arrangements are made for this child?

A. PREGNANCY AND BIRTH:

1. Mother’s age at birth of child?

2. Did mother have any illness during pregnancy?

Yes No

3. Did she take any medications other than vitamins and iron?

Yes No

4. Was the baby on time?

Yes No

5. What was the birth weight?

6. Did the baby have any trouble starting to breathe?

Yes No

7. Did the baby have any trouble while in the hospital? (jaundice, infections, other?)

Yes No

What kind?

B. PAST MEDICAL HISTORY:

1. Where has your child gone for check-ups until now?

2. Date of last check-up:

3. Date of last dental check-up:

4. Has your child had allergic reactions to any medications, foods, insect bites?

Yes No

If yes, which ones?

5. Has your child had reactions to any immunizations?

Yes No

If yes, which ones?

6. Any hospitalizations other than for birth?

Yes No

If yes, what for?

7. Any serious injuries?

Yes No

If yes, what kind?

8. Are any medications taken regularly?

Yes No

If yes, which ones?

C. FAMILY HISTORY:

1. Are the child’s parents both in good health?

Yes No

3. List age, sex, and general health of brothers and sisters

4. Have any of your children died?

Yes No

D. FEEDING AND NUTRITION:

1. Is your child’s appetite usually good?

Yes No

2. Is it good now?

Yes No

3. Was there severe colic or any unusual feeding problem during the first 3 months?

Yes No

4. Do any foods disagree with him/her?

Yes No

5. For the first 6 months, is he/she (was he/she) breast fed or bottle fed?

6. If still on formula, which one do you use?

7. Does he/she take vitamins?

Yes No

E. REVIEW OF SYSTEMS:

1. Has your child had frequent ear infections?

Yes No

2. Any eye problems?

Yes No

3. Has he/she had any problems with teeth?

Yes No

4. Does he/she have frequent colds or sore throats?

Yes No

5. Is there asthma, pneumonia, or recurrent cough?

Yes No

6. Does he/she have a heart murmur or any heart problems?

Yes No

7. Any problems with urination?

Yes No

8. Any problems with diarrhea or constipation?

Yes No

9. Have there been any convulsions or other problems with the nervous system?

Yes No

10. Any eczema, hives, or other skin conditions?

Yes No

11. Has your child ever been anemic?

Yes No

12. Please list any other medical problems

F. DEVELOPMENT/BEHAVIOR:

1. At what age did your child sit alone?

2. At what age did he/she walk alone?

3. Did he/she say any words by the time he/she was 1½ years old?

Yes No

4. How does this child compare to others his or her age?

Yes No

5. Does he/she have any trouble sleeping?

Yes No

6. What grade is he/she in?

Yes No

7. Has he/she had any trouble in school?

Yes No

8. Does he/she get along with other children?

Yes No

G. SAFETY/ENVIRONMENT:

1. Do you live in a private house, apartment, mobile home, other?

2. Do you know the hottest temperature of the water in your pipes?

Yes No

3. Is there a working smoke alarm on each floor in the house?

Yes No

4. Does your child always use a car seat/seat belt when riding in a car?

Yes No

5. Are there any smokers in the household?

Yes No

6. Are there any problems with the condition of your home? (peeling paint, insects, rats, or mice)

Yes No

7. Does your child always wear a helmet when riding his/her bicycle?

Yes No

H. DO YOU HAVE A RECORD OF IMMUNIZATIONS?

Yes No

Consent for the Use and Disclosure of Protected Health Information

Use and Disclosure of Your Protected Health Information

Your protected health information will be used by Partners in Pediatrics, LLC or disclosed to others for the purposes of treatment, obtaining payment or supporting the day-to-day health care operations of the practice.

Notice of Privacy Practices

You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent.

Requesting a Restriction on the Use and Disclosure of Your Information

You may request a restriction on the use and disclosure of your protected health information. Partners in Pediatrics, LLC may or may not agree to restrict the use and disclosure of your protected health information. If Partners in Pediatrics, LLC agrees to your request, the restriction will be binding on the practice. Use and disclosure of protected health information in violation of an agreed upon restriction will be a violation of the federal privacy standards.

Revocation of Consent

You may revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use and disclosure that has already occurred prior to the date on which your revocation of your consent is received will not be affected.

Reservation of Right to Change Privacy Practices

Partners in Pediatrics, LLC reserves the right to modify the privacy practices outlined in the notice.

Signature

I have reviewed this consent form and give my permission to Partners in Pediatrics, LLC for the use and disclosure of my health information in accordance with this consent.

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.

Patient Name

Signature (Parent or Guardian)

Date

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative’s Name

Relationship to Patient

Your information will be encrypted.