PEDIATRIC NEW PATIENT INFORMATION
Date: ______
PATIENT INFORMATION
Child’s Name: ______Child’s Nickname: ______
Reason for Visit: ______
Sex: M / F Date of Birth: ______Age: ______Child’s SS #: ______
Child’s Home Phone #: ______
Child’s Home Address: ______
Who may we thank for referring you? ______
FAMILY INFORMATION
Mother’s Name: ______Mother’s SS #: ______
Father’s Name: ______Father’s SS #: ______
Mother’s Phone: ______WORK / CELL / HOME
Father’s Phone: ______WORK / CELL / HOME
Parent’s Marital Status: Married ____ Single ____ Divorced ____ Widowed ____
List Ages of Other Children in Family: ______
CONSENT TO TREAT
Being the parent or legal guardian of this child, I hereby authorize this office and its doctors to examine and
administer care to my son / daughter named ______as the
examining / treating doctor deems necessary .
I understand and agree that I am personally responsible for payment of all fees charged by this office for such care.
Parent’s Name: ______Signature: ______
Date: ______Witnessed By: ______
Infant Patient History
3 months to 2 years
Today’s Date ______Patient’s Name ______
Sex: M F Date of Birth ______Age_____
Reason for Today’s Visit ______
The following questions are designed to help the doctor provide a detailed evaluation of your child.
Nutrition
Y / N Is your child still being breast fed? If no, for how long was he/she breast feed? ______
If still breast feeding, how much cows milk does mother consume each day? ______
Y / N Is your child formula fed? Which formula or other milk source? ______
Y / N Is your child eating solid food? What foods does his/her diet contain? ______
______What is your child’s favorite food? ______
Y / N Does your child have any feeding difficulties? ______
Y / N Does your child have any digestive disturbances? ______
Y / N Does your child have any food allergies? ______
Y / N Does your child have any persistent or intermittent skin rashes? ______
Y / N Is your child receiving any vitamin supplements? ______
Trauma
Y / N Has your child had any recent falls or trauma? Describe the trauma and date it occurred.
______
Y / N Has your child ever fallen down stairs or from any height? ______
Y / N Has your child ever been in a motor vehicle collision or near miss? ______
Y / N Has your child ever had a bone fracture or joint dislocation? ______
Y / N Has your child had any other trauma or injuries? ______
Y / N Does your child ever bang his/her head repeatedly against a wall, bed or other object? ______
Growth and Development
Y / N Can your child sit unsupported? At what age did your child start to sit-up? _____ months
Y / N Is your child crawling yet? At what age did your child start crawling? ______months
Y / N Is your child walking yet? At what age did your child start walking? ______months
Y / N Does your child often trip and fall? ______
Y / N Do you have any concerns about your child’s growth and development? ______
______
Health History
Y / N Has your child ever had colic? ______
Y / N Has your child had any upper respiratory infections? ______
Y / N Has your child had asthma? ______
Y / N Does your child ever complain of back or neck pain? ______
Y / N Does your child ever complain of pains in the arms or legs? ______
Y / N Does your child ever complain of headaches? ______
Y / N Has your child had any earaches? At what age did the first earache occur? ______
Y / N How frequently does your child get earaches? ______
Y / N Does your child’s earaches usually occur in the same ear? ____ Right ____ Left ____ Both
Y / N Has your child had any other illnesses?
Please list each illness and its approximate date ______
______
Y / N Is your child presently receiving any medications? ______
Y / N Has your child ever been to a hospital or emergency room for evaluation or treatment? ______
Y / N Has your child recently been vaccinated? ______
Y / N Do you have any other concerns about your child’s health? ______
APPOINTMENT REMINDERS
As a convenience to our patients we offer three options for your appointment reminders.
**Please choose only one option**
- OR -
- OR -
In addition, we will mail any written communication to the address you specified on your intake form, unless you request otherwise. Email communication is also for occasional news, special events, and office promotions. (HIPPA laws do not allow us to give your email or address to third parties). If you wish not to receive our emails, there is a removal button at the bottom of each email that will immediately remove you from future mailings.
______
Patient Signature Date