Welcome Form

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WELCOME TO OUR PRACTICE

Gender
Primary Address:

HOUSEHOLD

Please list all those living in the child’s house

BIRTH HISTORY

Was the baby born at term?
Did Parent #1 have any illness or problem with her pregnancy?
During pregnancy, did Parent #1: Smoke
Use drugs or medications:
Was the delivery:
Did your baby have any problems right after birth?
Was initial feeding:
Did your baby go home with Parent #1 from the hospital?

GENERAL

Do you consider your child to be in good health?
Does your child have any serious illness or medical condition?
Has your child had any serious injuries or accidents?
Had your child had any surgery?
Has your child ever been hospitalized?
Is your child allergic to any medicine or drugs?
Is your child allergic to any foods?

DEVELOPMENT

Are you concerned about your child’s physical development?
Are you concerned about your child’s mental or emotional development?
Are you concerned about your child’s attention span?
If your child is in school:

FAMILY HISTORY

Have any family members had the following:
Deafnes:
Nasal allergies:
Asthma:
Tuberculosis:
Heart disease or Stroke (before age 50):
High blood pressure (before age 50):
High cholesterol:
Anemia:
Bleeding disorder:
Liver disease:
Kidney disease:
Diabetes (before 50 years old):
Bed wetting (after 10 years old):
Epilepsy or convulsions:
Alcohol or drug abuse:
Death before 50 years old:
Mental illness:
Developmental Delay:
Immune problems, HIV/AIDS:

PAST HISTORY

Does your child have or has he/she ever had:
Chickenpox:
Frequent ear infections:
Problems with ears or hearing:
Nasal allergies:
Problems with eyes or vision:
Asthma, bronchitis, bronchiolitis, or pneumonia:
Any heart problem or heart murmur:
Anemia or bleeding problem:
Blood transfusion:
Frequent abdominal pain:
Constipation requiring doctor visits:
Bladder or kidney infections:
Bed wetting (after 5 years old):
(For girls) Has she started her menstrual period:
(For girls) Are there problems with her periods?:
Any chronic or recurrent skin problems (acne, eczema, etc.):
Frequent headaches:
Convulsions or other neurologic problems:
Diabetes:
Thyroid or other endocrine problems:
Any other significant problems:
Use alcohol or drugs:
Is your child on any current medications?

OTHER MEDICAL SPECIALISTS

Please list any other medical specialists that your child sees

AUTHORIZATION FOR TREATMENT

EMERGENCY CONTACT INFORMATION

PHARMACY INFORMATION

INSURANCE INFORMATION

 

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