Welcome Form WELCOME TO OUR PRACTICE Patient Name: Form Completed By/Relationship to Patient: Birth Date: Age: Today’s Date: MaleFemale Patient Social Security Number: Home Phone Number: Primary Address: City: State: Zip: Parent #1 Cell Number: Parent #2 Cell Number: Parent #1 Work Number: Parent #2 Work Number: Email Address: Fax Number: Referred By: HOUSEHOLD Please list all those living in the child’s house Name: Relationship to Child: Birth Date: Heath Problems: Name: Relationship to Child: Birth Date: Heath Problems: Name: Relationship to Child: Birth Date: Heath Problems: Are there siblings not listed? If so, please list their names ages and where they live: If Parent #1 and Parent #2 are not living together, or if child does not live with parent, what is the child’s custody status? If one or both parents are not living in the home, how often does he/she see the parent(s) not in the home? BIRTH HISTORY Birth Weight lbs oz. Was the baby born at term? YesNoEarlyLate If early, how many weeks gestation? Did Parent #1 have any illness or problem with her pregnancy? YesNo Explain: During pregnancy, did Parent #1: Smoke YesNo Use drugs or medications: YesNo What: When: Was the delivery: VaginalCesarean? If cesarean, why? Did your baby have any problems right after birth? YesNo Explain: Was initial feeding: BreastBottle? Did your baby go home with Parent #1 from the hospital? YesNo Explain: GENERAL Do you consider your child to be in good health? YesNo Explain: Does your child have any serious illness or medical condition? YesNo Explain: Has your child had any serious injuries or accidents? YesNo Explain: Had your child had any surgery? YesNo Explain: Has your child ever been hospitalized? YesNo Explain: Is your child allergic to any medicine or drugs? YesNo Explain: Is your child allergic to any foods? YesNo Explain: DEVELOPMENT Are you concerned about your child’s physical development? YesNo Explain: Are you concerned about your child’s mental or emotional development? YesNo Explain: Are you concerned about your child’s attention span? YesNo Explain: If your child is in school: What Grade? Name of 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 resources classes? FAMILY HISTORY Have any family members had the following: Deafnes: YesNo Who: Comments: Nasal allergies: YesNo Who: Comments: Asthma: YesNo Who: Comments: Tuberculosis: YesNo Who: Comments: Heart disease or Stroke (before age 50): YesNo Who: Comments: High blood pressure (before age 50): YesNo Who: Comments: High cholesterol: YesNo Who: Comments: Anemia: YesNo Who: Comments: Bleeding disorder: YesNo Who: Comments: Liver disease: YesNo Who: Comments: Kidney disease: YesNo Who: Comments: Diabetes (before 50 years old): YesNo Who: Comments: Cancer (indicate type and age of onset) Obesity: Bed wetting (after 10 years old): YesNo Who: Comments: Epilepsy or convulsions: YesNo Who: Comments: Alcohol or drug abuse: YesNo Who: Comments: Death before 50 years old: YesNo Who: Comments: Mental illness: YesNo Who: Comments: Developmental Delay: YesNo Who: Comments: Immune problems, HIV/AIDS: YesNo Who: Comments: Additional family history: PAST HISTORY Does your child have or has he/she ever had: Chickenpox: YesNo When: Frequent ear infections: YesNo Explain: Problems with ears or hearing: YesNo Explain: Nasal allergies: YesNo Explain: Problems with eyes or vision: YesNo Explain: Asthma, bronchitis, bronchiolitis, or pneumonia: YesNo Explain: Any heart problem or heart murmur: YesNo Explain: Anemia or bleeding problem: YesNo Explain: Blood transfusion: YesNo Explain: Frequent abdominal pain: YesNo Explain: Constipation requiring doctor visits: YesNo Explain: Bladder or kidney infections: YesNo Explain: Bed wetting (after 5 years old): YesNo Explain: (For girls) Has she started her menstrual period: YesNo When: (For girls) Are there problems with her periods?: YesNo Explain: Any chronic or recurrent skin problems (acne, eczema, etc.): YesNo Explain: Frequent headaches: YesNo Explain: Convulsions or other neurologic problems: YesNo Explain: Diabetes: YesNo Explain: Thyroid or other endocrine problems: YesNo Explain: Any other significant problems: YesNo Explain: Use alcohol or drugs: YesNo Explain: Is your child on any current medications? YesNo If Yes, please list: OTHER MEDICAL SPECIALISTS Please list any other medical specialists that your child sees Name: Type of Specialty: Name: Type of Specialty: Name: Type of Specialty: Name: Type of Specialty: AUTHORIZATION FOR TREATMENT In the event that I, (name of parent/guardian) am unable to accompany my child/children listed above, I authorize the following individual(s) to give permission for minor treatments in my absence: Name: Relationship: Name: Relationship: Name: Relationship: ` Name: Relationship: EMERGENCY CONTACT INFORMATION Name: Relationship to Child: Phone Number Best to Be Reached at: PHARMACY INFORMATION Pharmacy Name: Address: Phone Number: INSURANCE INFORMATION Name of Insurance: ID#: GRP#: Policy Holder Name: Employer: Employer Address: Current Pediatrician: Tel#: