Patient Name
DOB
ASHEVILLE MEDICINE & PEDIATRICS
PEDIATRIC REGISTRATION FORM
828.651.0121 (PHONE) | 828.651.0141 (FAX) | WWW.ASHEVILLEMEDPEDS.COM
CHILD’S INFORMATION – SEPARATE FORMS MUST BE COMPLETED FOR EACH CHILD IN A FAMILY
CHILD’S FULL NAME (FIRST MIDDLE LAST)
CHILD’S GENDER
PRIMARY HOME ADDRESS (NO P.O. BOXES)
CITY
STATE
ZIP
CHILD’S PRIMARY LANGUAGE
MALE
ENGLISH
FEMALE
OTHER
CHILD’S Social Security #
CHILD’S ETHNICITY
CHILD’S RACE
DECLINE
DECLINE
HISPANIC
AMERICAN INDIAN OR ALASKAN NATIVE
NON-HISPANIC
ASIAN
PRIMARY CELL PHONE
PRIMARY WORK PHONE
(
(
(
)
__________
FAMILY’S PRIMARY EMAIL ADDRESS
PRIMARY HOME PHONE
)
CHILD’S DATE OF BIRTH
SPANISH
BLACK OR AFRICAN AMERICAN
NATIVE HAWAIN OR PACIFIC ISLANDER
)
WHITE
OTHER
________________
MOTHER or LEGAL GUARDIAN’S INFORMATION
FATHER or OTHER LEGAL GUARDIAN’S INFORMATION
MOTHER/GUARDIAN’S FULL NAME
FATHER/GUARDIAN’S FULL NAME
MOTHER/GUARDIAN’S SOCIAL SECURITY #
MOTHER’S MAIDEN NAME OR GUARDIAN’S
FATHER/GUARDIAN’S SOCIAL SECURITY #
CHILD LIVES WITH (CHECK ONE)
RELATION TO THE PATIENT(IF APPLICABLE)
MOTHER
OTHER
MOTHER/GUARDIAN’S DATE OF BIRTH
MOTHER/GUARDIAN’S MARITAL STATUS
FATHER/GUARDIAN’S DATE OF BIRTH
FATHER/GUARDIAN’S MARITAL STATUS
SINGLE
MARRIED
SINGLE
SEPERATED
DIVORCED
SEPERATED
DIVORCED
STATE
MOTHER/GUARDIAN’S HOME PHONE
(
MOTHER/GUARDIAN’S EMPLOYER
WIDOWED
(CHECK IF SAME AS CHILD)
CITY
)
BOTH
MARRIED
WIDOWED
MOTHER/GUARDIAN’S MAILING ADDRESS
FATHER
______________
FATHER/GUARDIAN’S MAILING ADDRESS
ZIP
(CHECK IF SAME AS CHILD)
CITY
STATE
MOTHER/GUARDIAN’S CELL PHONE
FATHER/GUARDIAN’S HOME PHONE
FATHER/GUARDIAN’S CELL PHONE
(
(
(
)
MOTHER/GUARDIAN’S WORK PHONE
(
)
FATHER/GUARDIAN’S EMPLOYER
)
)
FATHER/GUARDIAN’S WORK PHONE
(
MOTHER/GUARDIAN’S EMAIL ADDRESS
ZIP
)
FATHER/GUARDIAN’S EMAIL ADDRESS
INSURANCE INFORMATION – THIS SECTION MUST BE COMPLETE OR PAYMENT IN FULL IS DUE AT TIME OF SERVICE
PRIMARY INSURANCE COMPANY NAME
SUBSCRIBER’S NAME
SUBSCRIBER’S DOB
SUBSCRIBER’S SS#
PATIENT’S RELATIONSHIP TO SUBSCRIBER
CHILD
OTHER
SECONDARY INSURANCE COMPANY NAME
SUBSCRIBER’S NAME
SUBSCRIBER’S DOB
SUBSCRIBER’S SS#
SELF
______________
PATIENT’S RELATIONSHIP TO SUBSCRIBER
CHILD
OTHER
SELF
______________
PREFERRED PHARMACY
NAME OF LOCAL PHARMACY
NAME OF MAIL in PHARMACY
ADDRESS OR INTERSECTION
ADDRESS OR INTERSECTION
PHONE (IF KNOWN)
FAX (IF KNOWN)
(
(
)
)
PHONE (IF KNOWN)
FAX (IF KNOWN)
(
(
)
)
***PLEASE CONTINUE ON THE BACK***
1
10.25.13
Patient Name
DOB
ASHEVILLE MEDICINE & PEDIATRICS
PEDIATRIC REGISTRATION FORM
828.651.0121 (PHONE) | 828.651.0141 (FAX) | WWW.ASHEVILLEMEDPEDS.COM
AUTHORIZED INDIVIDUALS ALLOWED TO ACCOMPANY MY CHILD FOR MEDICAL CARE AND RECEIVE MEDICAL RESULTS
Please list anyone who has your permission to bring your child to our office for medical care in your absence and/or who is authorized to receive your child’s medical information. In the
event of an emergency, only people you authorize in writing, per HIPAA requirements, will be able to accompany your child for treatment without you being present.
NAME OF AUTHORIZED INDIVIDUAL (Last, First, Middle Initial)
DATE OF BIRTH
RELATIONSHIP TO CHILD
PRIMARY PHONE
(
NAME OF AUTHORIZED INDIVIDUAL (Last, First, Middle Initial)
DATE OF BIRTH
RELATIONSHIP TO CHILD
)
PRIMARY PHONE
(
)
EMERGENCY CONTACT INFORMATION
Every effort is made to protect our patients’ privacy. However, in the case of an emergency in which a parent/legal guardian cannot be reached, we may need to call someone on your
child’s behalf. Please list below the name of someone your child does not live with and who we have your permission to contact if necessary.
NAME OF PERSON NOT LIVING WITH YOUR CHILD
RELATIONSHIP TO CHILD
EMERGENCY CONTACT’S PHONE NUMBER
(
)
CONSENT FOR TREATMENT
Consent for Treatment
As the parent or legal guardian of the patient listed below, I do hereby consent to the performance of routine diagnostic procedures and/or medical treatment
as deemed necessary or advisable by my child’s physician(s) at Asheville Medicine & Pediatrics. I hereby authorize Asheville Medicine & Pediatrics, LTD to
apply for benefits on my child’s behalf for all services rendered.
Parent/Guardian’s Name & Signature
Child’s Name
Print Parent/Guardian’s Full Name
Print Child’s Name
Date of Birth
Parent/Guardian’s Signature
Date of Signature
2
10.25.13
Patient Name
DOB
Asheville Medicine and Pediatrics
New Patient Medical History
Please fill out all sections completely.
PATIENT NAME: _________________________________________ DATE OF BIRTH: __________________________
Please list ALL medications you are currently taking. Be sure to include strength and directions for use.
_______________________________
______________________________
________________________
_______________________________
______________________________
________________________
_______________________________
______________________________
________________________
Are you allergic to any medication(s)?
YES
NO
If so, please list the medication and reaction: ___________________________________________________________
Please tell us about your medical history by checking the box beside any illness or condition that you have or have had in the past.
CARDIOVASCULAR
__ AORTIC ANEURISM
HEART DISEASE
__ HIGH BLOOD PRESSURE
__ VALVE PROBLEMS
__
__
__
__
PULMONARY
__ ASTHMA
__ PNEUMONIA
__ SLEEP APNEA
__ CHRONIC BRONCHITIS
__ PULMONARY EMBOLISM
__ TUBERCULOSIS
__ COPD/EMPHYSEMA
__ PULMONARY HYPERTENSION
__ OTHER: ____________________
GASTROINTESTINAL
__ CIRRHOSIS
__ HEARTBURN/GERD
__ PANCREATITIS
__ COLON POLYPS
__ HEPATITIS
__ PEPTIC ULCER DISEASE
__ CROHN’S DISEASE
__ IRRITABLE BOWEL SYNDROME
__ OTHER: ____________________
GENITOURINARY
__ RENAL FAILURE
__ DIFFICULTY URINATING
__ INCONTINENCE
__ ENLARGED PROSTATE
__ ERECTILE DYSFUNCTION
__ URINARY TRACT INFECTIONS
__ ENDOMETRIOSIS
__ KIDNEY STONES
__ OTHER: _____________________
MUSCULOSKELETAL
__ CHRONIC PAIN
__ GOUT
__OSTEOPOROSIS
__FIBROMYALGIA
__HIP REPLACEMENT
__ RHEUMATOID ARTHRITIS
__ BROKEN BONES: ___________
__ OSTEOARTHRITIS
__ OTHER: _____________________
ENDOCRINE/METABOLIC
__ DIABETES TYPE ONE
__ HYPERTHYROIDISM
__ DIABETES TYPE TWO
__ HYPOTHYROIDISM
__DYSMETABOLIC SYNDROME
__ OTHER: ______________________
___NEUROLOGICAL
__ ALZHEIMER’S DISEASE
__ MIGRAINE HEADACHES
__ PARKINSON’S DISEASE
__ADD/ADHD
__ TENSION HEADACHES
__ PERIPHERAL SENSORY NEUROPATHY
__ STROKE
__ TRANSIENT ISCEMIC ATTACK
__OTHER: ________________________
BLOOD DISORDERS
__ ANEMIA(PERNICIOS/IRON DEFF)
__ SICKLE CELL ANEMIA
__OTHER: ________________________
ALLERGY/DERMATOLOGY/OTHER
__ ALLERGIES
__RECURRENT SINUS INFECTIONS
__ ECZEMA
__INSOMNIA
__RECURRENT EAR INFECTIONS
__OTHER: ________________________
ARRHYTHMIA
DEEP VEIN THROMBOSIS
HEART ATTACK
HEART MURMUR
__
__
__
__
CONGESTIVE HEART FAILURE
HIGH CHOLESTEROL
PACEMAKER
OTHER: ____________________
__ CORONARY
Do you have any history of CANCER?
YES
NO
Where/What kind? ______________________________________________________ When? ______________________
Do you have any Vision impairment? YES
__
CATARACTS
__GLAUCOMA
NO
__MACULAR DEGENERATION
__ Blind
__OTHER ____________________
Do you have any Hearing impairment or are you deaf? YES
NO
If Yes, please describe and advise if you need any special communication assistance?
_______________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
3
10.25.13
Patient Name
DOB
PATIENT NAME: _________________________________________ DATE OF BIRTH: __________________________
Please tell us about your medical history by checking the box beside any illness or condition that you have or have had in the past.
All Adults and Adolescents between the ages of 12-18
Over the past two weeks, how often have you been bothered by any of the followings problems? (Please circle your
answers)
Little interest or pleasure doing things?
0=Not at all
1=Several days
2= More than half the days
3= Nearly every day
Feeling down, depressed or hopeless
0=Not at all
1=Several days
2= More than half the days
3= Nearly every day
Do you have Advance Care Planning? Yes or No If yes-please provide a copy, If no, do you want to discuss this with your physician
today?
FOR WOMEN:
____ AGE OF MENSES
__ ENDOMITRIOSIS
____IRREGULAR/HEAVY MENSTRUATION
__ HYSTERECTOMY
___MENOPAUSE _____ AGE
__ OTHER FEMALE PROBLEMS _______________________________________
_____________________ DATE OF LAST BONE DENSITY
________________________ DATE OF LAST MAMMOGRAM
HOW MANY Pregnancies? _______ Vaginal Births? ________ C-sections __________ Elective Abortions? _______ Miscarriages _______
Do you use birth control?
YES
No
When was your last PAP? ____________________________
If yes, what kind/method? __________________________________________
Any abnormality? ___________________________________________________
Please list any SURGERIES you have had and the dates they were performed.
_________________________________________
____/____/____
______________________________________
____/____/____
_________________________________________
____/____/____
______________________________________
____/____/____
_________________________________________
____/____/____
______________________________________
____/____/____
Additional Procedures: __ Colonoscopy (Date) ______________
__ Echocardiogram (Date) ____________________
__ Stress Tests (Date) _______________________
Family History: Please check all that apply and choose from the listed relations below to show history.
M- mother, F- father, S- sister, B- brother, Son- son, d- daughter, MGM-maternal grandmother
MGF- maternal grandfather, PGM- paternal grandmother, PGF- paternal grandfather
__ HIGH BLOOD PRESSURE _____
__ ENLARGED PROSTATE _____
__ FIBROMYALGIA
_____
__ HIGH CHOLESTEROL
_____
__ KIDNEY STONES
_____
__ OSTEOARTHRITIS
_____
__ HEART ATTACK
_____
__ ALZHEIMER’S
_____
__ OSTEOPOROSIS
_____
__ CANCER (WHAT TYPE)
_____
__ STROKE
_____
__ ALCOHOLISM
_____
__ ASTHMA
_____
__ MIGRAINES
_____
__ ANXIETY
_____
__ COPD/EMPHYSEMA
_____
__ SEIZURE DISORDER
_____
__ DEPRESSION
_____
__ CIRRHOSIS
_____
__ TIA’s
_____
__ GLAUCOMA
_____
__ IRRITABLE BOWEL(IBS) _____
__ DIABETES TYPE 1
_____
__ CATARACTS
_____
__ PANCREATITIS
_____
__ DIABETES TYPE 2
_____
__ OTHER _________________
__ HYPERTHYROIDISM
_____
__ HYPOTHYROIDISM
_____
ADULT VACCINES
__
TDAP (Date)
__________ __
Pneumonia (Date)
____________ __Flu (Date) ____________ __
Shingles(Date)
__________
Please list all VITAMINS OR DIETARY SUPPLEMENTS you use. Be sure to include strength and directions for use.
______________________________
_______________________________
4
__________________________
10.25.13
Patient Name
DOB
______________________________
_______________________________
___________________________
______________________________
_______________________________
__________________________
Please circle “yes” or “no” to each question or check all applicable answers.
Social History:
Are you Employed?
Are you Married?
Yes
No
Single
Do you have any children?
Retired? What was your occupation?
Widowed
Divorced
Yes No
If so, how many?
Do you smoke or use tobacco? Yes Nonsmoker
Did you quit smoking? Yes When?
Do you drink alcohol? Yes No
If so, how much/often?
If not, are you interested in quitting? Yes
No
If so, how much and how often
Do you suffer from any Mental or Emotional Disorders?
__ANXIETY
__EATING DISORDER
__DEPRESSION
__BIPOLAR DISORDER
__OBSESSIVE-COMPLUSIVE DISORDER
__OTHER
Please answer all questions below.
PEDIATRICS:
Parent’s Marital Status:
Married
Single
Separated
Divorced
Family members living in household:
Mother’s Occupation:
Father’s Occupation:
Is the child exposed to smoke in the home?
Yes No
Name of school child attends.
Grade:
Teams/Clubs:
5
10.25.13
Patient Name
DOB
Asheville Medicine & Pediatrics
Authorization for Release of Information – Compound Release
Name of Patient ___________________________________________ Date of Birth ______________
I, ______________________________ authorized to release protected health information about the above named
patient in the following manner and to identified persons.
Authorized Designees
Check each person/entity that you approve to receive
information.
Description of information to be released. Check each that
can be given to person/entity on the left in the same
section.
 Voice Mail- (Home, Cell phone, Emergency Contacts)  Results of lab tests/x-rays, Appointment Reminders
Other_______________________________
 Spouse (provide name and phone number)
______________________________________
______________________________________
 Parent (provide name and phone number)
_______________________________________
_______________________________________
 Emergency Contacts
______________________________________
______________________________________
 Financial
 Medical
 Any Exclusions_______________________________
 Financial
 Medical
 Any Exclusions_______________________________
 Financial
 Medical
 Any Exclusions_______________________________
 Authorized individuals that are allowed to accompany my child for medical care and/or receive medical results.
Please note: Only persons you authorized will be able to accompany your child for treatment.
__________________________________ ___________ , ____________________ __________________________
Name
DOB
Relationship to Child
Primary Phone
___________________________________________,__________________________________________________
Name
DOB
Relationship to Child
Primary Phone
Patient Rights:
 I have the right to revoke this authorization at any time.
 I may inspect or copy the protected health information to be disclosed as described in this document.
 Revocation is not effective in cases where the information has already been disclosed but will be effective going
forward.
6
10.25.13
Patient Name


DOB
Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and
may no longer be protected by federal or state law.
I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.
The information is released at the patient’s request and this authorization will remain in effect until
revoked by the patient.
_________________________________________________________
Signature of Patient or Personal Representative
Date ___________________
*Description of Personal Representative’s Authority (attach necessary documentation)
7
10.25.13
Patient Name
DOB
New Patients & Physical Exams
2 and Up
1.
Everyone 12 years and older
Over the past two weeks, how often have you been bothered by any of the followings problems? (Please
circle your answers)
0=Not at all
Little interest or pleasure doing things?
1=Several days
2= More than half the days
3= Nearly every day
0=Not at all
Feeling down, depressed or hopeless
1=Several days
2= More than half the days
3= Nearly every day
2.
Hearing Impairment questions (please circle your answers)
Do you have any hearing impairment? If yes,
please describe
No
Yes
If yes, please advise if you need any special
communication assistance today
No
Yes
3.
Vision impairment questions ( please circle your answers)
Do you any vision impairment? If yes, please
describe
If yes, please advise if you need any special
communication assistance today
4.
No
Yes
No
Yes
Patient and Family Medical History regarding Substance Abuse
Patient Substance Abuse
Family History of Substance Abuse
5. Advance Care Planning
Do you have “Advanced care Planning? For more
information on Advanced care planning please see
the back of this form.
If yes, please provide a copy of your information
If no, do you want to discuss this with your
provider today?
Alcohol
Other _______________________
None _______________________
Alcohol
Other _______________________
None________________________
No
Yes
No
Yes
8
10.25.13
Patient Name
DOB
Advanced Care Planning
Advanced Care Planning is making decisions about the care you would want to receive if you
become unable to speak for yourself. This planning may include getting information about the
types of treatments that may be available to you, deciding what treatments you would or
would not want, sharing your wishes with your loved ones, and completing advanced
directives in writing to ensure that your wishes are carried out. This planning is for all ages, as
accidents or illness may occur at any age.
For further information, please refer to the patient education videos on the Advanced Care
Planning website at www.acpdecisions.org. Your physician will be happy to discuss your advanced
care planning at today’s visit if you so desire. If you have completed advanced care planning
already, please provide a copy to our office.
Patients Signature
Date
9
10.25.13