New Client Questionnaire (Child)

Emergency Assistance

If this is an emergency, call:

911
Or go to your nearest Emergency Room

Client Information

First name

Last name

Nickname name

Date of birth

Insurance Front

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Insurance Back

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Secondary Insurance Front

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Secondary Insurance Back

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Drivers License Parent/Guardian 1

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Drivers License Parent/Guardian 2

Add file

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Additional ID Card

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Insurance Holder's Information

First name

Last name

Social Security Number

Date of Birth

Address

Telephone Number

Pharmacy Information

Name

Address

Phone Number

Fax Number

Parent or Guardian Information

Mother's First name

Mother's Last name

Father's First name

Father's Last name

Cell phone number

Secondary Cell phone number

Email address

Physical Address (Street, City, State, Zip Code)

I authorize messages to be left at the above phone numbers and the email to be used for correspondance

Medical History

Has the child been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for the visit

Please list the medications the child is taking and for what conditions. Include the dosage and amounts.

Please list any surgeries or time spent in the hospital (Date and Reason)

Please list any past illnesses or diagnosis (ADHD, allergies, etc.)

Please list any delayed milestones or developmental challenges.

Does the child have any allergies to medications?

Vaccine Record

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Growth Charts, Labs, Other files we may need

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Family History

Social History

Authorized Adults that Can Bring My Child and Consent for Vaccines and/or other Medical Care

Add another authorized adult

ID card for authorized adult

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Emergency Contact Information

Add another emergency contact

ID card for emergency contact

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Date

Name of Person Filling out Form

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Neighborhood Pediatrics

At Neighborhood Pediatrics we offer comprehensive care for your children. Please give us a call to schedule your appointment to discuss your child and any concerns you may have.