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Pediatric Health History
Name of Child
(Last) (First) (Middle)
Age Date of Birth Race Sex _______
Father=s Name Mother=s Name______________
Age Education Age Education_________________
Occupation Occupation
__________________
Who does the child live
with?__________________
Who is legally responsible
for the child? _____________________
Siblings:
Name, age & Health Problems Others in the Home?
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Prenatal & Birth History
How many times have you been
pregnant? How many live
births?_______
During this child=s pregnancy did you use vitamins alcohol
tobacco
drugs___
What type of delivery? vaginal or C- Section any complications____
Was this child premature? Birth Weight Length ______
Childhood Health Problems
Any known allergies_______________________________________________
Childhood illnesses_______________________________________________
Injuries _________________________________________________________
Surgeries_______________________________________________________
Does anyone in the home smoke? Yes No Whom______________________
Are the child=s immunizations up to date? Please
provide a copy of this record.
Other health concerns?______________________________________________
________________________________________________________________
________________________________________________________________
Family History
(please check all that apply)
~ Allergies ~ Diabetes ~ Cystic
Fibrosis ~ Heart Disease ~ Cancer
~ Drug Abuse ~ Hypertension ~ Birth defects ~ TB ~ Sickle cell
~ Asthma ~ Seizures
Signature of person completing form:_______________________________
PATIENT
NAME:
Birth date:
ADDRESS:
Social Security #:
Street,
Apt. No.
City:
State: Zip:
Home
Phone:( ) County: Sex:
Race: Religion:
MAIDEN NAME: (Single
patients or male patients give mother=s maiden
name)
Single ____ Married ____
Widowed ____ Separated ____ Divorced ____
PATIENT EMPLOYER
NAME:
ADDRESS:
Employer Phone: ( )
Street,
Appt.. No. City, State, Zip
Occupation:________Employment Status: Full Time____ Part Time ____ Retired ____Unemployed
____
PERSON TO NOTIFY
NAME:
ADDRESS:
Phone: (
) Relationship:
NEXT OF KIN (If same as person to notify leave blank)
NAME:
ADDRESS:
Phone: (
) Relationship:
GUARANTOR (Who is responsible for bill: Self or (Who
is bringing pt in today if minor)NOT INSURANCE )
NAME:
ADDRESS:
Phone:
( ) S.S. Number:
GUARANTOR EMPLOYER
NAME:
ADDRESS:
EMPLOYMENT STATUS: OCCUPATION_______ EMPLOYER PHONE: (
)______________
IF PATIENT IS A MINOR WE NEED BOTH PARENTS EMPLOYMENT INFORMATION. THIS SECTION IS
FOR THE PARENT THAT IS NOT LISTED IN THE
GUARANTOR INFORMATION ABOVE.
NAME:
____________________________SS#__________________DATE OF BIRTH____________
ADDRESS_____________________________ RELATIONSHIP TO
PATIENT___________
EMPLOYER ADDRESS
_________________________________PHONE: (____)_________
EMPLOYMENT STATUS______________________
INSURANCE POLICY
NUMBER COVERAGE NO. SUBSCRIBER REL
OFFICE COPAY
1.
2.
Primary
Care Physician: Reason
for Visit:
READ
AND SIGN
I hereby authorize payment directly to my physician=s office, of any Insurance coverage for treatment
rendered, and authorize them to release any information necessary to process
these insurance claims.
I understand that I am fully responsible for all social
services and charges, including any balance due after payment of insurance, and
that insurance coverage does not necessarily pay all charges.
I also understand that doctor and office fees are due
and payable when services are rendered.
I, the undersigned, authorize treatment by the
physician of this office.
SIGNATURE:
(If Minor, Parent or Guardian
Signature)
DATE: _______________