Patient Info Application

PEDIATRIC REGISTRATION/UPDATE FORM

TODAY’S DATE

PATIENT INFORMATION

First Name

First

Middle

Last Name*

Last Name

Social Security Number

Home Phone

Work Phone

Cell Phone

Email

Date of Birth

Age

Physician

Birth Gender

Current Gender

Preferred Pronoun (optional)

He, Him, His
She, Her, Hers
They, Them, Theirs
Ze, Hir

Gender Identity (optional)

Sexual Orientation (optional)

PARENT INFORMATION

Parent 1 Name

First Middle Last

Date of Birth

same address parent #1

Same Address as Child

Home Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Employer's Name

Employer's Address

Street Address Address Line 2 City State ZIP Code

Parent 2 Name

First Middle Last

Date of Birth

same address parent #2

Same Address as Child

Home Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Work Phone

Employer's Name

Employer's Address

Street Address Address Line 2 City State ZIP Code

Pediatric and Adolescent Medicine
New Patient Health History

Patient Full Name:

Birth Date:

Todays Date:

Gender:

Male
Female
Other

Patient Nickname:

Preferred Pronouns:

Primary Pediatrician:

Name of Person Completing This Form:

Relationship to Patient:

Parent/Guardian #1

Name:	Preferred Contact #:	Occupation:

Parent/Guardian #2

Name:	Preferred Contact #:	Occupation:

Parents Status:

Child Lives With:

Both Parent
Parent #1
Parent #2

Parent #1 %

Remarried

Remarried

Parent #2 %

Remarried

Remarried

Recent Family Changes or Stress?

Yes
No

Others In The Home:

Name	Age	Relationship

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?

Yes
No

Patient Attends:

Daycare
Sitter
Preschool
School

How many days of the week?

Please enter a number from 0 to 7.

Location

How many days of the week?

Please enter a number from 0 to 7.

Location

How many days of the week?

Please enter a number from 0 to 7.

Location

Grade:

Please enter a number from 0 to 12.

Location

Does your child receive any special services?

Yes
No

Untitled

IEP
504
Gifted
Therapy
Other

Concerns about relationships w/ friends, family, others?

Yes
No

Patient’s sports/activities/hobbies:

Home Environment/Safety:

What year was your home built?

Type:

Are there:

Carbon monoxide detectors
Smoke detectors
Fire extinguishers
Pool
Pets/Animals
Firearms
Smokers

Pool Locked?

Yes
No

How?

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.

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 Sheet

Date

Name

First Last

Date of Birth

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

PREFERRED LANGUAGE

ETHNICITY

Hispanic or Latino
Not Hispanic or Latino
Decline to Specify

CONTACT PREFERNCE

Signature