Pediatric New Patient Intake Form
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1 Name: DOB: Page 1 of 5 Pediatric New Patient Intake Form Patient Information Last Name: First Name: DOB: Home Mobile Preferred (circle) : Home / Cell Gender: Primary Pediatrician: Pediatrician Address: Referring Provider: Referring Address: Preferred Pharmacy: Preferred Pharmacy Address: Parent 1 Name: DOB: Occupation: Marital Status: Spouse: Parent 2 Name: DOB: Occupation: Marital Status: Spouse: Collection of the following information is encouraged by federal health agencies. This information is used to monitor and improve the quality of care provided to all patients. Ethnicity: Race: Decline Response Decline Response Black or African American Hispanic or Latino American-Indian or Alaska Native Native Hawaiian or Pacific Islander Not Hispanic or Latino Asian White Other Preferred Language: Decline Response Patient Financial Obligation Agreement I understand that all applicable copayments and deductibles are due at the time of service. I agree to be financially responsible and make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to ColumbiaDoctors for services rendered. I authorize representatives of ColumbiaDoctors to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. Notice of Privacy Practices: Acknowledgement of Receipt I acknowledge that I was provided with a copy of the ColumbiaDoctors Notice of Privacy Practices (NOPP). Received N/A (only if you received the notice from ColumbiaDoctors previously) mycolumbiadoctors Patient Portal Sign Up Access your child s (or your) personal records securely, 24/7, on a computer, smartphone, or tablet. See brochure for details. Patients 11 and younger: Send an invitation to join mycolumbiadoctors to the address circled above for Parent 1 / Parent 2. Opt out Patients 12 and older: Send an invitation to join mycolumbiadoctors to the patient address above. Opt out Look for an invite from noreply@followmyhealth.org and click the Registration link. Insurance Plan information Disclosure and Consent ColumbiaDoctors will provide you with information regarding the health plans that your provider(s) accepts*. If you decide to be treated by a provider who does not accept your health plan, you will be asked to sign a consent form agreeing that you accept treatment from that provider. I read and agree to all of the above (Financial Agreement, Notice of Privacy, Portal Sign Up, Insurance Information). Patient or Legal Guardian Name (Print): Patient or Legal Guardian Signature: Date: *Please refer to our website, columbiadoctors.org, for a list of insurances accepted by your provider. Version 1.8 Updated: 6/17/2016
2 Name: DOB: Page 2 of 5 Medical and Social History Reason for today s visit: Is patient adopted? Y N If Y, please answer the following to the best of your knowledge. Which pregnancy is patient? Birth weight: Born by: C-Section Vaginal Delivery Weeks gestation at birth? If C-section, why? Please describe any health problems the mother or patient experienced during pregnancy or after birth, if any: Does the patient have any allergies to medications or other substances (pets, plants, food, etc.)? Y N If yes, please list allergies and reactions (including rash, hives, throat swelling, anaphylaxis): Allergy Reaction Allergy Reaction Please list ALL current medications, including over-the-counter, supplements, and herbs: Medication Name Dose Medication Name Dose Please list any past surgeries and hospitalizations and the approximate date. Procedure/ Hospitalization Date Reason Complications Has the patient EVER had any of the following? Anemia/Bleeding tendency... Y N Ear/Nose/Throat... Y N Asthma/Breathing problems... Y N Eczema/Skin disorder... Y N Behavioral problems... Y N Eye Disorder... Y N Blood Transfusion... Y N Growth disorder... Y N Bowel/Stomach problems... Y N Heart disorder/defect... Y N Cancer/Leukemia... Y N Kidney/Bladder problems... Y N Chicken Pox/Shingles... Y N Liver disease... Y N Developmental disorder... Y N Seizure or Epilepsy... Y N Diabetes... Y N Thyroid disorder... Y N Please list any other medical illnesses or problems and provide details for any of the above conditions: Version 1.8 Updated: 6/17/2016
3 Additional Pediatric Orthopedic Information: Please answer ALL QUESTIONS to the best of your ability OFFICE USE ONLY Name: Age: MRN# Height: Weight: BP: Temp: If female, age of 1st menses? CHIEF COMPLAINT Reason for today s visit: Symptoms/complaints & date of onset: Pain severity: scale of 1 (no pain) to 10 (worst pain imaginable). Circle number below: Pain is (Circle): Dull? Sharp? Tingling? Other: Pain occurs? (Circle) At rest? With activity? At night? What do you use to reduce the pain? (Circle): Medicine? Ice? Heat? Rest? Elevation? Is problem improving, worsening or stable? Other symptoms associated with the current problem? Is there a family history of this problem? If this is an injury, how did it occur? Have you seen any other doctors (including in an ER) for this? If yes, whom, when, what treatment was given? FAMILY HISTORY Patient s Mother s health: Father s health: Patient s Sister/Brother s health: Patient s Sister/Brother s health:
4 SOCIAL HISTORY What is your child s grade in school N/A Do they attend a special needs facility (specify) Languages spoken at home (circle all that apply): English Spanish Other Who lives at home with you? Frequency of Exercise/Organized Sports (circle): Daily Weekly Monthly Gym Class Only Rarely/ Never Specific type of exercise/ sports: Describe any braces or orthotics your child uses including pattern of use: Does your child receive: Physical Therapy? No Yes Frequency School based? Y N Speech Therapy? No Yes Frequency School based? Y N Occupational Therapy? No Yes Frequency School based? Y N Is child enrolled in Early Intervention or Birth to 3? Y N DEVELOPMENTAL DATA At what age did patient first: Sit: Stand Walk? Special concerns with development? Reviewed by:,m.d. Date:
5 PLEASE LIST ALL DOCTORS/PROVIDERS TO WHOM WE SHOULD SEND A REPORT NAME SPECIALTY ADDRESS PHONE NUMBER Parent/Guardian signature: Date: Scan Folder: Registration Form Revised 1/5/16
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