Patient Registration Form

Patient Name (Last, First)

DOB

Gender

Male Female Other

Parent # 1 Name (Last, First

DOB

Occupation

Address

City/State

Zip Code

Parent Mobile #

Employer

Home #

Parent # 2 Name (Last, First

DOB

Occupation

Address

City/State

Zip Code

Parent Mobile #

Employer

Home #

Child’s parents are

Married Separated Divorced

Other

Emergency Contact/Relationship

Phone #

Primary Language(s) Spoken at Home

English Other

If other, please specify.

Ethnicity

Asian

White

Hispanic/Latino

American Indian

African American

Pacific Islander

Other

Add Sibling

Social History/ Safety Issues

Who lives in the home?

Do any household members smoke?

Yes No

Do you have a gun in your home?

Yes No

Are they locked up?

Yes No

Are there any pets in your home?

Yes No

(Specify)

Does your child attend daycare/preschool/school?

Yes No

Grade

School Name

Any concerns about school performance?

Yes No

(Specify)

Birth History

Delivery Hospital

Your Ob

Were there any problems with the pregnancy?

Yes No

(Specify)

Was the baby

full term premature

If so, how early?

NICU

Yes No

If yes, reason for NICU hospitalization?

Delivered by

Vaginal Birth Caesarian

(Please explain why:)

Birth Weight

Birth Length

Passed Hearing Screen?

Yes No

Patient Medical History

Allergies

Yes No

If yes; specify.

Does your child Take

Vitamins

Supplements

Special Diet

Medications

If yes, please explain.

Has your child had any surgeries?

Yes No

If yes, please list year and type of surgery below.

Has your child had any hospitalizations/Illnesses/Injuries?

Yes No

If yes, please list year and explain below.

Has your child seen any specialists/therapists?

Yes No

If yes, please list doctor(s), and reason for specialty care.

Please check below if your CHILD has/has any of the following?

Other

Family History (Please specify which family member) text

Alcoholism/Drug abuse

Specify family member

ADHD/Learning Disabilities

Specify family member

Asthma

Specify family member

Allergies/ Hay fever

Specify family member

Food allergy

Specify family member

Bleeding/Clotting problems

Specify family member

Depression/Mental illness/ anxiety

Specify family member

Diabetes (specify)

Specify family member

Eczema

Specify family member

Kidney Disease

Specify family member

Seizures/Febrile seizures

Specify family member

Thyroid disease (specify)

Specify family member

High Cholesterol

Specify family member

High Blood Pressure

Specify family member

Congenital hearing loss

Specify family member

Heart attack (before 50)

Specify family member

Heart disease/Sudden unexplain death before age 50

Specify family member

Inherited genetic disease/birth defects; (specify)

Specify family member

Other

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