Time of Appointment: Date of Appointment:

Doctor: Referred by:

Childs Full Name: Birthdate: Male: Female:

Social Security #: Home Phone:

Address: City:

State: Zip:

Guardian:

Name:

Birthdate: Home Phone: Cell Phone:

Employer: Business Phone:

Guardian:

Name:

Birthdate: Home Phone: Cell Phone:

Employer: Business Phone:

Payment Type:

Person Responsible for Account:
Statements are sent to this Address

Name: Check here if address is same as above. Address: City:

State: Zip: Primary Insurance:

Subscriber's Name:

Subscriber I.D. #: Group #: Co-Pay Amount:

Insurance Company:

Insurance Company Address: City:

State: Zip:

Relationship to Patient:

Social Security #: Birthdate:

Secondary Insurance:

Subscriber's Name:

Subscriber I.D. #: Group #: Co-Pay Amount: Insurance Company:

Insurance Company Address: City:

State: Zip:

Relationship to Patient:

Social Security #: Birthdate:

Siblings:

     First/Last Name: Birthdate: Male: Female:      
     Social Security #:        
     First/Last Name: Birthdate: Male: Female:      
     Social Security #:      
     First/Last Name: Birthdate: Male: Female:      
     Social Security #:      
     First/Last Name: Birthdate: Male: Female:      
     Social Security #:

Child's Health History:

Former Doctor: Office Phone:

Address:

City: State: Zip:

Date of last doctor visit: Child's Height: Weight:

School: Grade:

Does your child take vitamins, fluoride, iron or other supplements? Yes: No:

Please list any medications your child is currently taking:

Please check all that apply to your child:

Allergies Ear Infections Kidney/Bladder Problems
Anemia Eating Problems Mumps, Measles
Asthma Eczema/Skin Problems Pneumonia
Bed Wetting Emotional Problems Rheumatic Fever
Cancer Epilepsy Sleeping Problems
Chicken Pox Eye Problems Speech Problems
Congenital Heart Defect HIV/AIDS TB/Lung Disease
Convulsions/Epilepsy Handicaps/Disabilities Temper Problems
Croup Hearing Problems Thumb Sucking
Dental Problems Heart Murmur Toilet Training Problems
Developmental Problems Hemophilia Tonsillitis
Diabetes Hepatitis-Type Tuberculosis
Diarrhea or Constipation High Blood Pressure Other:
Discipline Problems High Cholesteral  

Please describe any special medical problems:

Birth History:

Birth weight:

Was the baby born at term? Early? Late?

If early, how many weeks' gestation?

Did the mother have any illness or problem with her pregnancy? Yes. No.         Explain:

During pregnancy, did mother:

Smoke? Yes. No.
Drink Alcohol? Yes. No.
Use drugs or medications? Yes. No.

If so, what?

And when? 

Cesarean Delivery?

If cesarean, why?

Did your baby have any problems right after birth? Yes. No.         Explain:


Was initial feeding breast? Or bottle?

Did your baby go home with mother from the hospital?

Yes. No.         Explain:

General:

Do you consider your child to be in good health?

 Yes. No.

Does your child have any serious illness or medical condition?

 Yes. No.

Has your child had any serious injuries or accidents?

 Yes. No.

Has your child had any surgery?

 Yes. No.

Has your child ever been hospitalized?

 Yes. No.
Is your child allergic to any medications or drugs? Yes. No.

Development:

Are you concerned about your child's physical development? Yes. No.
Are you concerned about your child's mental or emotional development? Yes. No.
Are you concerned about your child's attention span? Yes. No.

If your child is in school:

How is his/her behavior in school?
Has he/she failed or repeated a grade in school?
How is he/she doing in academic subjects?
Is he/she in special or resource classes?

Family History:
Have any family members had the following:

Deafness Yes. No. Who?
Nasal Allergies Yes. No. Who?
Asthma Yes. No. Who?
Tuberculosis Yes. No. Who?
Heart Disease (before 50 years old) Yes. No. Who?
High Blood Pressure (before 50 years old) Yes. No. Who?
High Cholesterol Yes. No. Who?
Anemia Yes. No. Who?
Bleeding Disorder Yes. No. Who?
Liver Disease Yes. No. Who?
Kidney Disease Yes. No. Who?
Diabetes (before 50 years old) Yes. No. Who?
Bed-wetting (after 10 years old) Yes. No. Who?
Epilepsy or Convulsions Yes. No. Who?
Alcohol Abuse Yes. No. Who?
Drug Abuse Yes. No. Who?
Mental Illness Yes. No. Who?
Mental Retardation Yes. No. Who?
Immune Problems, HIV, or AIDS Yes. No. Who?

Additional family history:

Past History:
Does your child have, or has he/she ever had:

Chicken pox Yes. No.
Frequent ear infections Yes. No.
Problems with ears or hearing Yes. No.
Nasal allergies Yes. No.
Problems with eyes or vision Yes. No.
Asthma, Bronchitis, Bronchiolitis, or Pneumonia Yes. No.
Any heart problem or heart murmur Yes. No.
Anemia or bleeding problem Yes. No.
Blood transfusion Yes. No.
Frequent abdominal pain Yes. No.
Constipation requiring doctor visits Yes. No.
Bladder or kidney infection Yes. No.
Bed-wetting (after 5 years old) Yes. No.
(For girls) Has she started her menstrual periods? Yes. No.
(For girls) Are there problems with her periods? Yes. No.
Any chronic or recurrent skin problem (acne, eczema, etc.) Yes. No.
Frequent headaches Yes. No.
Convulsions or other neurologic problem Yes. No.
Diabetes Yes. No.
Thyroid or other endocrine problem Yes. No.
Any other significant problem Yes. No.

Any other pertinent information :