Patient Info Application Patient Info Application PEDIATRIC REGISTRATION/UPDATE FORMTODAY’S DATE Date Format: MM slash DD slash YYYY PATIENT INFORMATIONFirst Name First Middle Middle Last Name* Last Name Social Security NumberHome PhoneWork PhoneCell PhoneEmail Date of Birth Date Format: MM slash DD slash YYYY AgePhysicianBirth GenderFemaleMaleNoneUndifferentiatedUnknownCurrent GenderFemaleMaleNoneUndifferentiatedUnknownPreferred Pronoun (optional)He, Him, HisShe, Her, HersThey, Them, TheirsZe, HirGender Identity (optional)FemaleFemale to Male (FTM) Transgender Male/Trans ManMaleMale to Female (MTF) Transgender Female/Trans WomanGenderqueer/Non-Binary Neither Exclusively Male or FemaleChoose Not to DiscloseSexual Orientation (optional)Straight/HeterosexualAsexualLesbian/Gay/HomosexualBisexualUncertain/Don’t KnowSomething Else, Please DescribePARENT INFORMATIONParent 1 Name First Middle Last Date of Birth Date Format: MM slash DD slash YYYY same address parent #1 Same Address as Child Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneEmployer's Name First Employer's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent 2 Name First Middle Last Date of Birth Date Format: MM slash DD slash YYYY same address parent #2 Same Address as Child Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneEmployer's Name First Employer's Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pediatric and Adolescent MedicineNew Patient Health HistoryPatient Full Name: Full Name Birth Date: Date Format: MM slash DD slash YYYY Todays Date: Date Format: MM slash DD slash YYYY Gender:MaleFemaleOtherPatient Nickname: First Preferred Pronouns: First Primary Pediatrician: First Name of Person Completing This Form: First Relationship to Patient:Parent/Guardian #1Name:Preferred Contact #:Occupation: Parent/Guardian #2Name:Preferred Contact #:Occupation: Parents Status:SingleMarriedDivorcedSeperatedChild Lives With:Both ParentParent #1Parent #2Parent #1 %Remarried Remarried Parent #2 %Remarried Remarried Recent Family Changes or Stress?YesNoOthers In The Home:NameAgeRelationship If Yes, Please Explain:In the last year did you worry about or run out of food and not have enough money to buy more?YesNoPatient Attends: Daycare Sitter Preschool School How many days of the week?Please enter a number from 0 to 7.LocationHow many days of the week?Please enter a number from 0 to 7.LocationHow many days of the week?Please enter a number from 0 to 7.LocationGrade:Please enter a number from 0 to 12.LocationDoes your child receive any special services?YesNoUntitled IEP 504 Gifted Therapy Other Concerns about relationships w/ friends, family, others?YesNoPatient’s sports/activities/hobbies:Home Environment/Safety:What year was your home built?Type:HouseApartmentCondoTrailerAre there: Carbon monoxide detectors Smoke detectors Fire extinguishers Pool Pets/Animals Firearms Smokers Pool Locked?YesNoHow?What Kind?How are the firearms stored?Who Smokes?Where do they smoke?Does your child: Wear a helmet appropriately Use sunscreen appropriately (SPF 15 or above) Know how to swim (or take lessons if 4 or older) When riding in a car, my child uses: Rear-facing car seat (<2y) Front-facing car seat (until weight exceeds seat specifications) Booster (belt positioning booster seat until 4'9") Seat Belt in back seat Seat belt in front seat (>12y) Please record your child’s Family Medical History below: I previously completed a Family History for this patient. I have multiple children here TODAY and have completed this TODAY on the form. Patient adopted; No Biologic Family History available. Patient adopted; Limited Biologic Family History recorded below. Patient conceived by IVF with donor. (only include details of blood relatives below) No changes since. (You may stop here.) New information added below. Completed this TODAY on the form of child:IVF Type: Egg Sperm Have any blood relatives of THIS PATIENT had these conditions (parents, siblings, grandparents, aunts, uncles)? Please include details for all checked boxes, including which relatives and whether on father’s or mother’s side. ADD/ADHD Alcoholism Allergies Asthma Birth Defects Blood/Bleeding disorders Bowel Disease (Ulcerative colitis, Crohn’s, Irritable Bowel) Cancer (include type) Deafness Depression Developmental delays Diabetes (Type 1 or Type 2?) Early death/SIDS Eczema Family or inherited diseases Heart attack before age 55 Heart disease High cholesterol/lipids/triglycerides High blood pressure Hip dysplasia Immune disorders Kidney Disease Learning Disability Liver Disease Lung Disease Mental Health (Anxiety, Bipolar, Depression, etc.) Mental Retardation Metabolic Disorders Migraines Neurologic disease Obesity Scoliosis Seizures/Epilepsy Serious or fatal childhood illness Strabismus (“Lazy eye”) Substance abuse Thyroid disease Tuberculosis Other Include which relatives and whether on father’s or mother’s side. (ADD/ADHD)Include which relatives and whether on father’s or mother’s side. (Alcoholism)Include which relatives and whether on father’s or mother’s side. (Allergies)Include which relatives and whether on father’s or mother’s side. (Asthma)Include which relatives and whether on father’s or mother’s side. (Birth Defects)Include which relatives and whether on father’s or mother’s side. (Blood/Bleeding disorders)Include which relatives and whether on father’s or mother’s side. (Bowel Disease)Include which relatives and whether on father’s or mother’s side. (Cancer)Include which relatives and whether on father’s or mother’s side. (Deafness)Include which relatives and whether on father’s or mother’s side. (Depression)Include which relatives and whether on father’s or mother’s side. (Developmental delays)Include which relatives and whether on father’s or mother’s side. (Diabetes)Include which relatives and whether on father’s or mother’s side. (Early death/SIDS)Include which relatives and whether on father’s or mother’s side. (Eczema)Include which relatives and whether on father’s or mother’s side. (Family or inherited diseases)Include which relatives and whether on father’s or mother’s side. (Heart attack before age 55)Include which relatives and whether on father’s or mother’s side. (Heart disease)Include which relatives and whether on father’s or mother’s side. (High cholesterol/lipids/triglycerides)Include which relatives and whether on father’s or mother’s side. (High blood pressure)Include which relatives and whether on father’s or mother’s side. (Hip dysplasia)Include which relatives and whether on father’s or mother’s side. (Immune disorders)Include which relatives and whether on father’s or mother’s side. (Kidney Disease)Include which relatives and whether on father’s or mother’s side. (Learning Disability)Include which relatives and whether on father’s or mother’s side. (Liver Disease)Include which relatives and whether on father’s or mother’s side. (Lung Disease)Include which relatives and whether on father’s or mother’s side. Mental Health (Anxiety, Bipolar, Depression, etc.)Include which relatives and whether on father’s or mother’s side. (Mental Retardation)Include which relatives and whether on father’s or mother’s side. (Metabolic Disorders)Include which relatives and whether on father’s or mother’s side. (Migraines)Include which relatives and whether on father’s or mother’s side. (Neurologic disease)Include which relatives and whether on father’s or mother’s side. (Obesity)Include which relatives and whether on father’s or mother’s side. (Scoliosis)Include which relatives and whether on father’s or mother’s side. (Seizures/Epilepsy)Include which relatives and whether on father’s or mother’s side. (Serious or fatal childhood illness)Include which relatives and whether on father’s or mother’s side. (Strabismus)Include which relatives and whether on father’s or mother’s side. (Substance abuse)Include which relatives and whether on father’s or mother’s side. (Thyroid disease)Include which relatives and whether on father’s or mother’s side. (Tuberculosis)Include which relatives and whether on father’s or mother’s side. (Other)Patient Information SheetDate Date Format: MM slash DD slash YYYY Name First Last Date of Birth Date Format: MM slash DD slash YYYY PATIENT DEMOGRAPHIC QUESTIONNAIRE Please note that we are requesting this optional information as an attempt to comply with federal “Meaningful Use” guidelines, as released by The Office of the National Coordinator for Health Information Technology. More information regarding these guidelines is available at http://healthit.hhs.gov You are NOT obligated to respond in order to be treated. If you do not wish to provide this information, please simply fill in your name, date and select the “Decline to Respond” choice. Please select the below as appropriate:RACE Asian Greek Alaskan Native Hawaiian American Indian or Alaskan Native Hispanic Black/African American Indian Native Hawaiian/Other Pacific Islander Multiracial White Native American Indian More than one race Other Pacific Islander (Not Hawaiian) Other race Pacific Islander Unknown Decline to Specify PREFERRED LANGUAGEEnglishSpanishBosnianRussianItalianFrenchGermanChineseJapaneseCentral KhmeHaitian; Haitian CreoleHebrewPortugueseKoreanSomaliArabicSpanish CastilianVietnameseHindiPolishThaiBulgarianUrduSwahiliDecline to SpecifyETHNICITYHispanic or LatinoNot Hispanic or LatinoDecline to SpecifyCONTACT PREFERNCECell PhoneConfidentialEmail/PortalHome PhoneMailWork PhoneDecline to SpecifySignature