new patient information - abcd pediatrics- new … patient packet... · 2017-08-01 · new patient...

New Patient Information

(*) Indicates optional information requested under the Affordable Care Act, including Ethnicity (Hispanic or Non-Hispanic) and Race (Caucasian, Hawaiian, Pacific Islander, Black, American Indian, Alaskan, Asian)

Guarantor is the contact with financial responsibility for medical care

*Ethnicity: Hispanic or Non-HispanicProvider: _______________________

*Race: White/Hawaiian-PacificIslander/Black/AmericanIndian-AlaskanNative/AsianPrimary Language: ____________

D.O.B. __________ Sex: _____

Doctors/ProvidersStone Oak: J. Laura Arnold, MD; M. Suzanne Basey, MD; Tiffany D. Cress, CPNP; Steven R. Fischer, MD; Jessica M. Gonzalez, MD; Alissa G. Hernandez, MD; Ann Kuri, MD; Katie G. Pegram, MD; Amy Quirke, CPNP; Richard T. Schlosberg, MD; Samuel D. Tressler III, MD; Jennifer M. Welty, MD; Kristin M. Wilke, MD

Schertz: David Diaz de Leon, MD; Nicolas N. Guerra, MD; Suzanne E. Hood, DO; Amy Quirke, CPNP; Najma A. Rinard, MD; Susannah L. Simone, MD; Michelle A. Wheeler, CPNP

New Braunfels: Amy D. Garcia, MD; Melissa A. Garcia, MD; Amy Quirke, CPNP

Bulverde: Tiffany D. Cress, CPNP; Megan C. Guerra, MD; James A. Hyslop, MD; Amy Quirke, CPNP; Kristin M. Wilke, MD;

Boerne: Kathryn D. Buck, MD; Rachel A. Gravel, MD; Sheralyn D. Wood, MD

Name (Last, First, MI):________________________________________________

*Race: White/Hawaiian-PacificIslander/Black/AmericanIndian-AlaskanNative/Asian

Sex: _____D.O.B. __________Lives w/ Parent/Guardian:___________Primary Language: ____________

Guarantor:______________________________*Ethnicity: Hispanic or Non-HispanicProvider: _______________________



Sex: _____Lives w/ Parent/Guardian:___________

D.O.B. __________Primary Language: ____________




Sex: _____D.O.B. __________

Lives w/ Parent/Guardian:___________Primary Language: ____________




Sex: _____Lives w/ Parent/Guardian:___________

D.O.B. __________Primary Language: ____________



Lives w/ Parent/Guardian:___________

Name (Last, First, MI):________________________________________________Provider: _______________________*Ethnicity: Hispanic or Non-Hispanic

Primary Language: ____________*Race: White/Hawaiian-PacificIslander/Black/AmericanIndian-AlaskanNative/Asian

Lives w/ Parent/Guardian:___________D.O.B. __________ Sex: _____

Guarantor:______________________________

Guarantor:______________________________

Primary Insurance:

Secondary Insurance/Medicaid:

Policy Holder's Name:________________________ Policy holder's D.O.B:_____________ Policy Holder's Sex:_______Insurance Carrier:___________________________ ID#____________________________ Group#__________________Group Name:_______________________________

Policy Holder's Name:________________________Insurance Carrier:___________________________Group Name:_______________________________

Policy holder's D.O.B:_____________ID#____________________________

Policy Holder's Sex:_______Group#__________________

Contact Information (Complete all items for parents, only bold items for other authorized contacts):

Street Address:__________________________City, State & Zip:_________________________Home Phone:____________________________Work Phone:____________________________Cell Phone:_____________________________Relationship to Pt(s):______________________

Birthdate________________________

Home Email:________________________________

Work EMail:_________________________________

Occupation:_________________________________

Employer:__________________________________Lives with Patient?________________

Name (Last, First, MI):________________________________________________________

Name (Last, First, MI):________________________________________________________Street Address:__________________________City, State & Zip:_________________________Home Phone:____________________________Work Phone:____________________________Cell Phone:_____________________________Relationship to Pt(s):______________________

Lives with Patient?________________

Birthdate________________________

Home Email:________________________________

Work EMail:_________________________________

Occupation:_________________________________

Employer:__________________________________





Birthdate________________________

Home Email:________________________________

Work EMail:_________________________________

Occupation:_________________________________

Employer:__________________________________

Birthdate________________________

Home Email:________________________________

Work EMail:_________________________________

Occupation:_________________________________

Employer:__________________________________

EMail Text*Preferred Method of Contact: Preferred Number: HM Cell WKPhonePlease Note: Ideally we prefer to contact parents via email for appointment reminders and general information unless

otherwise specified. If you wish to be contacted by other means, please indicate on the form.

Patient Name:________________________________________ Date of Birth:_______________

Name (Please print) Signature Date

Responsible Party:

If parents are divorced or separated, please fill out this section:Who has primary custody?Are there any legal restrictions that would prevent the non-custodial parent from consenting to medical treatment for the child or from obtaining information about the child's medical treatment? Yes/No

If Yes, please explain and provide a copy of any legal paperwork that supports this restriction:

ABCD Pediatrics Patient Authorization

Please read, initial, and sign below.

(Initial) Financial Policy: I acknowledge that I received, reviewed, and agree to comply with the most recent version of the

ABCD Pediatrics Financial Policy dated July 1, 2015.

(Initial) Financial Responsibility: I understand that I am ultimately responsible for payment on my child’s/children’s account.

Payment is expected at the time of service. I understand I am responsible to pay my co-pay, co-insurance, or deductible according to

my insurance contract at the time of service.

(Initial) Insurance Coverage: I understand that I am responsible to provide ABCD Pediatrics with my current insurance

coverage information and insurance card at each and every visit. I will be responsible for paying any balances due as a result of not

providing my most current insurance information. I understand that ABCD Pediatrics will not retroactively file claims due to my failure

to provide current insurance information.

(Initial) Assignment of Benefits: I hereby authorize payment directly to ABCD PEDIATRICS, for medical benefits otherwise

payable to me. I authorize my insurance company to disclose to ABCD PEDIATRICS, information regarding my insurance coverage,

including, but not limited to verification of my examination and/or treatment to my insurance company and/or other third party payor.

(Initial) No Show Fee: I acknowledge that I received, reviewed, and agree to comply with the ABCD Pediatrics No Show

Policy and agree to pay any fees incurred from failure to comply.

(Initial) Fee for Forms: I understand that I received notice about the fee for all forms to be completed by ABCD Pediatrics

and I agree to pay prior to form completion.

(Initial) Privacy Policy: I acknowledge that I received, reviewed, and agree to comply with the ABCD Pediatrics Privacy Policy.

(Initial) Immunization Policy: I acknowledge that I received, reviewed, and agree to comply with the ABCD Pediatrics

Immunization Policy.

(Initial) Consent to Treat: I have the legal right to consent to medical and surgical treatment for this patient. I voluntarily

authorize and consent to the medical care, treatment and diagnostic tests that providers of ABCD Pediatrics believe are necessary for

my child. I understand that by signing this form, I am giving permission to the doctors, nurses, and other healthcare providers in this

medical office to provide treatment to this child as long as my child/children are a patient in this practice.

(Initial) E-Prescribing: I voluntarily authorize ABCD Pediatrics to allow E-Prescribing for patient’s prescription, which allows

healthcare providers to electronically transmit prescriptions to the pharmacy of my choice, review pharmacy benefit information and

medical dispense history as long as this child is a patient at this office.

(Initial) I understand I am able to withdraw my consent at any time by contacting ABCD Pediatrics in writing at 19238

Stonehue, San Antonio, TX 78258.

Patient Name: DOB:

Siblings: DOB:

DOB:

DOB:

Parent/Guardian name (Print):

Parent/Guardian Signature:

Today’s Date:

ABCD Pediatrics Immunization Policy

At ABCD Pediatrics we are dedicated to providing the highest quality of evidence-

based medical care to our patients. This includes our adherence to the vaccine

schedule recommended by national organizations such as the American Academy

of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), and the

Advisory Committee on Immunization Practices (ACIP).

These well-respected organizations and committees include panels of experts in

pediatrics as well as infectious disease. The goal is to eliminate or minimize

preventable serious disease, thereby promoting the health of all children. These

national experts routinely analyze available information and research, monitor

the prevalence of vaccine-preventable diseases, and analyze reported serious

adverse events following vaccine administration. This information is used to

create the best vaccine schedule to protect your child. Be aware that there are

vaccines used in other countries that are not routinely used in the United States

to protect those children from even more diseases.

At ABCD Pediatrics we strive to provide the highest quality care, while respecting

the wishes of our parents. Should a family desire to alter the schedule or

withhold all recommended vaccines, ABCD Pediatrics feels that this decision not

only puts your child at risk of serious preventable disease, but also contributes to

the health risk of others.

Please be advised that if you desire an “alternate” vaccine schedule, or if you

intend to refuse vaccines, you do so against the advice of ABCD Pediatrics, the

AAP, the AAFP and the ACIP. Because we believe that this decision puts your child

at risk for vaccine preventable disease and increases health risks for others, ABCD

Pediatrics respectfully declines to be your children’s pediatricians. Thank you.

ABCD PEDIATRICS FINANCIAL POLICY

(Effective July 1, 2015)

Thank you for choosing ABCD Pediatrics as your children’s health care provider. We appreciate your trust in us and the

opportunity to carry out our mission statement, “To provide caring and informed attention to your children’s health and

wellbeing as they grow and thrive into adulthood.”

Our office and physicians make a great effort to get insurance companies to pay their share of the cost of this care in a

timely manner. However, due to the recent changes brought on by the Accountable Care Act, this is becoming more

challenging. We have therefore implemented a new Financial Policy; please read and sign the policy acknowledgement

form. If you have any questions, please ask to speak with the Office Manager.

PATIENT PAYMENTS

Payment (co-payments or co-insurance) is due at the time of service. If your child/children have an outstanding balance,

please make sure whoever accompanies the patient to the visit is prepared to pay it. We accept cash, check, or a

credit/debit card to pay your account. A current credit card will be kept on file. Please give your credit card to the

front office staff to scan into your account with this form. (Our software securely encrypts and stores your credit card

information displaying the last 4 digits of your credit card number only. No employee or outside vendor will ever have

access to your information.) The credit card will be encrypted and stored into your secured patient file, and used to

cover your balance according to the terms of this policy.

FIRST STATEMENT

Your insurance policy is a contract between you and your insurance company. This contract requires that we collect

certain co-payment or prepayment amounts depending upon the type of insurance and insurance carrier at the time of

service.

Regardless of your insurance status, when we determine that you owe a balance, we will mail a statement to the mailing

address provided to us by you. If your address changes, you are responsible for notifying us. All statements are also

available on our secure patient portal. Payment is due upon receipt of the statement.

Please contact our office as soon as possible after receipt of your statement should you have any questions, or should

you wish to discuss the outstanding balance. Should you need it, we can help you set up a payment plan with a valid

credit card. One-third (1/3) of the total balance is due the first day of the payment plan. The credit card used will

automatically be charged for the second and remaining third owed on a monthly basis. We require payment plans to

be arranged before your bill is 30 days old. In the event that your insurance pays us after that time, you will be

reimbursed.

PROMPT PAY DISCOUNT

ABCD Pediatrics provides a prompt pay discount to those uninsured patients who pay for services at the time of service,

thereby avoiding billing and collection costs by the practice. These discounts are set at 30% off the retail price of a Sick

Office Visit and 50% off the retail price of a Preventative/Well Office Visit. Discounts do not apply to any services other

than office services. Prompt pay discounts are not offered to insured patients where ABCD Pediatrics is contractually

required to accept a specific fee schedule. However, we do everything we can to mitigate the expense of anyone who

is underinsured.

SUBSEQUENT STATEMENTS AND UNPAID BALANCES

If your account remains unpaid, subsequent statements will be sent to the address we have on file. Although ABCD

Pediatrics does not charge interest for amounts past due and left unpaid by insurance or patient, a $5.00 statement fee

will be included for additional statements sent on unpaid balances.

When your balance is 90 days past due, your credit card will be charged for the full amount owed. If declined, your

account will be frozen and turned over to an outside collection agency for non-payment. Collection agency balances

require that we will no longer be able to provide healthcare services to your child/children. We continue to provide 30

days of emergent care to give you time to find another physician, and we work with you through any current treatment

plans. In this event, the Guarantor of the account agrees to pay any fees incurred by the collection agency.

INSURANCE COVERAGE

While we make a good faith effort to verify your coverage, we are not liable to guarantee that the information given to

us by your insurance is correct. It is your responsibility to know what services may or may not be covered by your

insurance. We encourage you to refer to your benefits manual if you have any questions about covered services and

work with us to make sure that these services are provided at the most cost efficient manner.

I agree to provide ABCD Pediatrics with the most current and accurate insurance information as it applies to my child’s

account. I will notify the office of any changes to insurance agree to the assignment of benefits. Finally, in the event that

insurance information you provide delays payment, you will be asked to pay in full billed charges and seek

reimbursement from your insurance provider directly. The insurance company gives us a very small window in which

to file a claim, and incorrect insurance information usually delays this beyond their window.

THIRD PARTY PAYORS

Our office does not bill third party payors, such as motor vehicle accident claims or worker’s compensation claims. If

you wish to see our doctors for a visit that would normally require us to bill a third party payor, you are required to pay

for the visit and/labs in full as a self-pay patient, and we will provide you with what you need to submit the claim

yourself.

CHILD ADVOCACY

As an advocate for our young patients, ABCD Pediatrics will not intervene in any custody dispute or financial

responsibility dispute between parents or other responsible parties. We will send statements to any one address

provided; however, we cannot look to more than one party for financial responsibility.

MISSED/LATE CANCELLED APPOINTMENTS

We require a 24 hour notice for cancelation of a Preventative Visit/Well Check-Up, and a 2 hour notice for a Sick

Appointment. This courtesy will allow others to be seen in a timely manner. If you are more than 15 minutes late for

your scheduled appointment, the physician will have to determine whether the appointment will need to be re-scheduled.

Missed appointments will be subject to a NO-SHOW fee as follows:

1st Missed Appointment $35

2nd Missed Appointment $75

3rd Missed Appointment $100

After the 3rd No Show, you may be asked to find another healthcare provider.

FEES

ABCD Pediatrics reserves the right to charge the following fees:

Medical Records $25.00

School/Sports/Camp/Daycare $ 5.00

Authorization for Services/Medication $ 5.00

FMLA Paperwork $25.00

Missed Appointments/No Show Fees $35/$75/$100

Emergency Walk-in Fee $25.00

We welcome the opportunity to discuss any aspect of our financial policy. Please ask to speak with the Office Manager

if you have any questions, comments, or concerns. We thank you for your support and look forward to serving you in

the future.

www.abcdpediatrics.com

J. Laura Arnold, M.D. Samuel T. Tressler, III, M.D. Ann Kuri, M.D. Richard T. Schlosberg IV, M.D. Nicolas N. Guerra, M.D. Megan C. Guerra, M.D. M. Suzanne Basey, M.D. Susannah L. Simone, M.D. Katie G. Pegram, M.D. Kristin M. Wilke, M.D. Esther J. Johnson, M.D. David D. de Leon, Jr. M.D. Jessica M. Gonzalez, M.D. Suzanne E. Hood, D.O. Najma A. Rinard, M.D. Steven R. Fischer, M.D. Melissa A. Garcia, M.D. Donna Egbulefu, M.D. James A. Hyslop, M.D. Amy D. Garcia, M.D. Michelle Wheeler, CPNP

19238 Stonehue 2200 Roy Richard Dr. 2115 Stephens Place, #900 121 Bulverde Crossing, #100 San Antonio, TX 78258 Schertz, TX 78154 New Braunfels, TX 78130 Bulverde, TX 78163 P: 210-494-2223 P: 210-566-4777 P: 830-214-6708 P: 210-499-6400 F: 210-494-2631 F: 210-566-4779 F: 830-358-7711 F: 210-494-2631

PREVENTATIVE HEALTH CARE AND SICK VISITS

Good health care for newborns, infants, children, and adolescents begins with the well-child visit (checkup) and other services that help keep children healthy. These are preventive services. Our doctors and staff provide these services based on a plan called Bright Futures. The American Academy of Pediatrics (AAP) made this plan to help doctors and families know what preventive services children should receive from birth to 21 years of age, such as screening tests, and advise about staying healthy and safe. This plan can be altered to suit each child as needed. We also follow the AAP vaccine schedule for newborns, infants, children, and adolescents.

Because preventive services are important to keeping children healthy, the Patient Protection and Affordable Care Act (health care reform law) includes a rule that all preventive care screenings and services included in the Bright Futures plan and vaccine schedule must be covered by most health plans. This is not always true, though, as some older plans, called grandfathered plans, do not have to pay in full for preventive services.

Health Plan Terms to Know

Co-payment: A fixed amount that you pay for certain health services before the health plan pays

Coinsurance: The portion of the charge that is not paid by the health plan (usually a fixed percent of each amount paid by the plan)

Deductible: An amount that must be paid before the health plan pays for covered services

There may also be times when a child needs a service that is not considered preventive on the same day as a well-child visit. If a child is not well or a problem is found or needs to be addressed during the checkup, the physician may need to provide an additional office visit service (called a sick visit) to care for the child. This is a different service and is billed to your health plan in addition to the preventive services provided on that day. If you have a co-payment for office visits or coinsurance or deductible amounts that you must pay before your health plan pays for these services, our office will charge you these amounts.

We value your time and want to make the most of each appointment for the child. This is why we will address any problem that needs a doctor's care during well-child visits so that only one trip is needed. Some services that may be provided and billed in addition to preventive services include:

• The doctor's work to address more than a minor problem, which will be billed as an office visit (eg, if the doctor gives a prescription, orders tests, or changes care for a known problem)

• Medical treatments (eg, breathing treatments)

• Any surgery (eg, removing splinters or something the child put in his or her nose or ear)

• Tests performed in the office that are not included in the Bright Futures plan

Our office does not want you to be surprised by a bill but must always bill your health plan based on the actual services provided. Please feel free to ask questions about services that may not be paid in full by your health plan on the day of your visit. It is our pleasure to help.

ABCD Pediatrics Patient Portal?

In an ongoing effort to support our parents and patients, we encourage you to register on the Patient Portal. The portal provides parents a secure link to health records and the ability to communicate with us on a variety of healthcare needs. Please refer to our website (http://www.abcdpediatrics.com/patient-services/patient-portal/). A full explanation is available for your review.

To register and take advantage of everything the portal has to offer, please send us an email at ([email protected]) with the following information:

• patient(s) name, date(s) of birth, your name, your relationship to patient(s), and your email address

We will complete the registration process and email a temporary password to you. When you log on, the system will prompt you to create a more personalized and secure password.

Access to a number of health-related services is now available to include:

• Viewing/printing immunization records• Viewing/printing growth charts• Viewing/printing recent visits• Viewing/printing a problem list• Email reminders• Send and receive documents• Access to statements• Maintaining demographic information• Lab results• Referral coordination• Prescription refills• Digitally complete required questionnaires prior to your visit• Online access to secure messaging with a Triage Nurse and designated members of our staff• Completing required developmental surveys (CHADIS)

Our website also includes the Pediatric Advisor, a reliable resource providing information and education on many healthcare topics.

http://www.abcdpediatrics.com/patient-services/patient-portal/

http://www.abcdpediatrics.com/patient-services/patient-portal/

https://portal.abcdpediatrics.com/

mailto:[email protected]?subject=Portal%20Registration%20Request%20&body=Please%20register%20me%20on%20the%20new%20portal.%0A%0APatient(s)%20name%3A%0ADate(s)%20of%20birth%3A%20%0AYour%20name%3A%0ARelationship%20to%20patient(s)%3A%0AEmail%20address%3A%0A%0AWhen%20we%20complete%20your%20request%20you%20will%20receive%20an%20e-mail%20with%20a%20temporary%20password.%20%20Once%20you%20log%20on%2C%20the%20system%20will%20prompt%20you%20to%20create%20a%20more%20personalized%20and%20secure%20password.%20%20

www.abcdpediatrics.com

19238 Stonehue 2200 Roy Richard Dr. 2115 Stephens Place, #900 121 Bulverde Crossing, #100 San Antonio, TX 78258 Schertz, TX 78154 New Braunfels, TX 78130 Bulverde, TX 78163 P: 210‐494‐2223 P: 210‐566‐4777 P: 830‐214‐6708 P: 210‐499‐6400 F: 210‐494‐2631 F: 210‐566‐4779 F: 830‐358‐7711 F: 210‐494‐2631

Our Mission: To provide caring and informed attention to your children’s health and wellbeing as they grow and thrive into adulthood.

Patient Centered Medical Home

We strive to be the “Medical Home” for your children and provide equally for all our patients a safe environment where you can expect to receive a comprehensive assessment and a personalized treatment strategy based on the most current evidence based guidelines. We will conduct surveys from time to time, and ask that you answer thoughtfully as we will use your feedback to guide us toward quality improvement that is important to you.

Please think of us as the first place to come for advice and care regarding all your child’s health care needs. This includes physical, developmental and emotional health, as well as a place to help you find the appropriate specialist or access community resources. We also want to coordinate your care. Let us know if you have been treated by a specialist, an emergency department or any outside healthcare professional. Informing us of medications, test results, and procedures are keys to having a complete understanding of your child’s health. Every time you are seen for care outside of our office, please request that a copy of the visit or test result is sent/faxed to us so that we can best serve you.

In addition, let us know if you are using any over‐the‐counter medications or have undertaken any self‐care regimens. Review your patient information on the patient portal and tell us if the information we have on file is incomplete or inaccurate. Good care requires a partnership between your family and our office. We appreciated your help and look forward to working with you.

For additional information please visit:

http://www.abcdpediatrics.com/about/patient‐centered‐medical‐home/

www.ncqa.com/consumers

Initial History Questionnaire Name of Patient: ___________________________ Birth date: ________________________ Age: _______________ Form Completed by: _______________________ Date: ___________________ Relationship:__________________

HOUSEHOLD

Please list all those living in the child’s home

Name Relationship To child

DOB Health Problems

What is the child’s living situation if they are not with both biological parents?

o Lives with adoptive parents?

o Lives with foster family?

o Joint custody?

o Sole custody?

If one or both parents are not living in the home, how often does the child see the parent(s) not in the home

BIRTH HISTORY (for children under age 2 only) Don’t know birth history

Birth Wt ______________ Was baby born term? Yes No How many weeks at time of delivery __________________ Were there any prenatal or neonatal complications? Yes No If yes, explain: __________________________________ Was NICU stay required? Yes No If yes, explain:__________________________________________________________ Was the delivery Vaginal Cesarean If Cesarean, why?____________________________________________________ During pregnancy, was child exposed to: Tobacco: Yes No Alcohol: Yes No Drugs or Medications: Yes No If yes to any above, please explain: _____________________________________________________________________ Did mother take prenatal vitamins: Yes No Did baby go home with mother from hospital? Yes No If no, explain____ ______________________________ How long was baby breastfed: ______________ Is baby: Breastfed Formula

GENERAL DK = Don’t know

Do you consider your child to be in good health? Yes No DK Explain:______________________________________ __________________________________________________________________________________________________ Does your child have any chronic medical conditions? Yes No DK Explain:___________________________________ __________________________________________________________________________________________________ Has your child had any surgeries? Yes No DK Please list dates/ages:______________________________________ __________________________________________________________________________________________________ Has your child been hospitalized ? Yes No DK Please list dates/ages:_______________________________________ __________________________________________________________________________________________________ Is your child allergic to medications or drugs? Yes No DK Please list medication and reaction type (hives, rash, etc.)______________________________________________________________________________________________ Do you feel your family has enough to eat ? Yes No DK Explain: ___________________________________________

BIOLOGICAL FAMILY HISTORY DK=Don’t Know (Include parents, grandparents, parents’ siblings & immediate family)

Have family members had the following:

Nasal Allergies or other allergies Yes No DK Who Comment

Asthma or other lung disease Yes No DK Who Comment

Heart disease or heart condition Yes No DK Who Comment

High blood pressure Yes No DK Who Comment

High cholesterol Yes No DK Who Comment

Diabetes/endocrine disorders Yes No DK Who Comment

Cancer Yes No DK Who Comment

Anemia Yes No DK Who Comment

Bleeding disorders Yes No DK Who Comment

Epilepsy or convulsions Yes No DK Who Comment

Mental /developmental disorder Yes No DK Who Comment

ADD/ADHD Yes No DK Who Comment

Page 1 of 2

Biological Family History DK=Don’t Know (Cont.)

Liver Disease Yes No DK Who Comment

Gastrointestinal disorder Yes No DK Who Comment

Kidney disease Yes No DK Who Comment

Bed Wetting (>10 Yrs) Yes No DK Who Comment

Hearing impairment Yes No DK Who Comment

Vision impairment/eye disorder Yes No DK Who Comment

Immune Problems (HIV/AIDS) Yes No DK Who Comment

Alcohol /Drug Use Yes No DK Who Comment

Mental Illness (Depression/Anxiety) Yes No DK Who Comment

Tuberculosis Yes No DK Who Comment

Additional family history______________________________________________________________________________

PASTMEDICAL HISTORY DK=Don’t Know

Does your child have or has your child ever had:

Chickenpox Yes No DK When

Sinus infections Yes No DK Explain

Ear infections Yes No DK Explain

Phayrngitis/tonsillitis Yes No DK Explain

Infectious illnesses (Aids/HIV/Hepatitis) Yes No DK Explain

Allergies/seasonal /food allergies Yes No DK Explain

Animals Yes No DK Explain

Outdoor allergens Yes No DK Explain

Indoor allergens Yes No DK Explain

Respiratory problems/asthma Yes No DK Explain

Heart problems Yes No DK Explain

Gastrointestinal problems (GERD) Yes No DK Explain

Urinary tract infections/kidney reflux Yes No DK Explain

Vision problems Yes No DK Explain

Hearing problems Yes No DK Explain

Skin conditions (eczema/psoriasis) Yes No DK Explain

Anemia or bleeding problem Yes No DK Explain

Blood transfusion Yes No DK Explain

Neurologic problems (ADHD/ADD) Yes No DK Explain

Mental health concerns Yes No DK Explain

Orthopedic problems Yes No DK Explain

Endocrine problems (diabetes) Yes No DK Explain

Thyroid/other endocrine problems Yes No DK Explain

If female, any problems w/ periods? Yes No DK Explain

Obesity/overweight Yes No DK Explain

Alcohol/drug/tobacco use Yes No DK Explain

ADHD/Anxiety/Depression Yes No DK Explain

Developmental delay Yes No DK Explain

Convulsions/seizures/neuro problems Yes No DK Explain

Frequent headaches (daily/weekly) Yes No DK Explain

Sleep problems/snoring Yes No DK Explain

History of fractures/concussions Yes No DK Explain

High blood pressure Yes No DK Explain

History of family violence/abuse Yes No DK Explain

Girls only: Has had her first period Yes No Age of first period if applicable:_______________ Any other significant problems:______________________________________________________________________

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new patient information - abcd pediatrics- new … patient packet... · 2017-08-01 · new patient...

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