New Pediatric Intake Form
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1 Dr Angela Knapp at Well Essentials 16904 SE 1 st St, Suite 104, Vancouver, WA 98684 Ph: 360-601-2567 Fx: 360-326-9567 www.DrAngelaKnapp.com DrAngelaKnapp@gmail.com New Pediatric Patient Intake Form Name _______________________________________ Date of First Visit _______________ Mother ______________________________________ Father ____________________________ Address _________________________________________________________________ City ____________________________ State ______________ Zip Code ___________ Telephone # (home)_______________________ (work) _________________________ E-mail _________________________________ S.S.# _______________________ Age ______ Date of Birth ___________________Gender: female ____male ____other ____ Occupation _______________________ How did you hear about our clinic? ___________________________________________ Next of Kin or other to reach in an emergency ___________________________________ Relationship ____________________ Phone __________________________________ HEALTH HISTORY QUESTIONNAIRE SUCCESSFUL HEALTH CARE AND PREVENTIVE MEDICINE ARE ONLY POSSIBLE WHEN THE PHYSICIAN HAS A COMPLETE UNDERSTANDING OF THE PATIENT PHYSICALLY, MENTALLY AND EMOTIONALLY. PLEASE COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE. PRINT ALL INFORMATION AND MARK ANYTHING YOU DON'T UNDERSTAND WITH A QUESTION MARK. Are you currently receiving healthcare? Y N If yes, where and from whom?_______________________________________________ ________________________________________________________________________ What are your most important health problems? List as many as you can in order of importance. Please include date of onset, frequency, severity and any past treatments. 1) 2) 3) 4) 5) 2 Medical History: Check those applicable Cancer Chronic Pain Diabetes Heart Disease High Blood Pressure Blood clots/disorder Stroke Epilepsy Mental Illness Asthma/Hayfever/Hives Anemia Anorexia/unable to eat Autoimmune Disease Arthritis GI/ Stomach issues Depression/Anxiety Hepatitis Chicken Pox Scarlett Fever Rheumatic Fever Seizure Migraines Thyroid issues Kidney Disease Glaucoma Tuberculosis YES ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Family Comments: ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ Type: ___________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ How many a month:________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ ______ ________________________________ Hospitalization and Surgery What hospitalizations or surgeries have you had? year: year: year: year: year: year: X-Rays and Special Studies X-rays, MRI, CAT scans, or other studies you have had: ________________________________________________________________________ ________________________________________________________________________ 3 BIRTH MOTHER Previous pregnancies by natural mother, miscarriages or complications____________ ______________________________________________________________________________________________ Mothers age at child’s birth ________ Mothers health during pregnancy: Other: __________________________________________ ____bleeding ____hypertension ____nausea ____ diabetes ____thyroid problems ____ physical or emotional trauma ____illness _________________________ ____cigarettes, alcohol, drugs BIRTH HISTORY Term: Full ___ Premature___ Late ___ Weight at Birth _______ Length of Labor ____________ Complications _____________________________________ As a baby, did your child have any of the following problems?: Jaundice Colic Blue Baby Diarrhea Fever CP Allergies Rashes _________________ Seizures Birth Defects_________ Birth Injuries _____________________ Other _________________________________________________________________________________________________________ Feeding: Breast Fed ________ How long? ______ Age began: Solid Foods ________ Sitting ________ Formula __________ Milk/Soy ________________ Crawling ________ Walking _________ First Words ________ Child’s sleep patterns first year __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Immunization History: Please circle all completed Hep B Rotavirus (RV) Diptheria/Tetanus/Pertussis(DTaP) Hib Pneumococcal (PPSV23) Polio Flu Varicella/chicken pox Measles/Mumps/Rubella (MMR) Hep A Meningococcal Human Papillomavirus (HPV) 4 Body Systems Check Please circle: Current- Weight__________ Height __________ Y= A condition your child has now N= Never Had P= Has had in the Past Hives YNP burning of urine YNP bloody urine YNP Eczema YNP frequent urination YNP cries easily YNP Bleeding gums YNP heart murmur YNP nervous YNP Nose bleeds YNP vomiting spells YNP sleep problems YNP Acne YNP anemia YNP night sweats YNP High fevers YNP stomach aches YNP sensitive to light YNP Chronic rash YNP jaundice YNP body/breath odor YNP Hearing loss YNP easy bruising YNP motion/car sick YNP Diarrhea YNP flatfeet YNP no appetite YNP Sore throats YNP constipation YNP nightmares YNP Frequent headaches Y N P gas YNP canker sores YNP Frequent colds YNP bleeding tendency YNP unusual fears YNP Wheezing YNP joint pains YNP excessive fatigue YNP Cough YNP dizzy spells YNP hair loss YNP Other condition(s) not listed: ____________________________________________________________________________________ Describe A Typical Days Diet: Breakfast: Lunch: Dinner: Snacks: Desserts: (how often) Fluids (include type and amount): Where do you grocery shop? _____________________________ How often do you eat out? _____________________ Do you buy Organic Foods? YES_____ NO_______ How much of the following would be found in the foods you eat on a daily basis? Synthetic sugars_________ Preservatives_________ Colors/Dyes ___________Synthetic chemicals_______ Does child crave: Sugar_____ Salt_______ Fats______ Pop _______other_________ 5 Allergies Are you hypersensitive or allergic to... Any drugs? Any foods? Any environmentals? Current Medications Do you take or use? Laxatives Y N Pain relievers Y N Cortisone Y N Appetite suppressants Tranquilizers Y N Thyroid medication Antacids Y N Y N Antibiotics Y N Sleeping pills Y N Y N Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking? 1) _________________________________ 4) _________________________________ 2) _________________________________ 5) _________________________________ 3) _________________________________ 6) _________________________________ Age of first menses? Age of last mense? Length of cycle? Duration of menses? Painful menses? Heavy or excessive flow? PMS? If yes, what are your symptoms? Endometriosis? Ovarian cysts? Difficulty conceiving? Cervical Dysplasia? Sexual difficulties? Gonorrhea? Herpes? Are you sexually active? Do you do breast self exams? Breast pain/tenderness? FEMALE REPRODUCTION Y Y Y Y Y Y Y Y Y Y Y Y Y Are cycles regular? days Bleeding between cycles? days Pain during intercourse? P N Clotting? P N Discharge? P N Birth control? What type? Number of pregnancies Number of live births P N Number of miscarriages P N Number of abortions P N Menopausal symptoms? P N Abnormal PAP? P N Chlamydia? P N Condyloma? P N Syphilis? N Sexual orientation: P N Breast lumps? P N Nipple discharge? Y Y Y Y Y Y Y P N P P P P P N N N N N N Y P N Y P N Y P N Y P N Y P N Y P N 6 YOUR HEALTH INFORMATION PRIVACY RIGHTS Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain privacy rights concerning your health care information. Under this law your health care provider generally cannot give your information to your employer, use or share your information for marketing or advertising purposes, or share private notes about your mental health counseling sessions without your written consent. As one of your health care providers it is our responsibility to keep your information safe and secure. We also need to make sure that your information is protected in a way that does not interfere with your health care. It is important that you understand that your information can be used and shared in the following ways: _____ For your treatment and care coordination. Multiple health care providers may be involved in your treatment directly and indirectly. _____ With your family, friends, relatives, or others that you identify who are involved in your health care or health care bills. _____ To protect the public’s health, such as reporting when the flu is in your area. _____To make required reports to the police, such as gunshot wounds. _____Obtain payment from third party payers. In order to provide you with service that best meets your privacy needs, please tell us how best to contact you when needed. Please check all that apply: _____Please do not phone me at home. Use this alternate phone number: ______________________ _____Please do not phone me at work. Use this alternate phone number: ______________________ _____Please do not leave messages on my answering machine. _____Please do not contact me by email. _____Please send mail, including my bills, to this alternate address: _______________________________ _____________________________________________________________________________________ Other request (please describe): __________________________________________________________ _____________________________________________________________________________________ Patient/Guardian Signature________________________________________________Date:_______________________ (If patient is a minor) Patient Name (Please Print): _________________________________________________________
