Age 3 and Under
Patient Information
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
SSN
*
Date of Birth
*
-
Month
-
Day
Year
Date
Sex at Birth
*
Please Select
Male
Female
Contact Information
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Contact Preference: Ok to leave confidential messages
*
Home
Cell
Don't leave confidential messages
MCMC occasionally uses text messages or email for appointment reminders and other general information. I consent to be contacted via
Text
Email
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Patient
*
Income Information
Total household income last month
Total persons living in household last month
Decline to provide household income
*
Please Select
Yes
No
MCMC offers a sliding fee discount program. Would you like more information about the assistance program:
*
Yes
No
General Information
Marital Status
*
Single
Married
Widowed
Divorced
Student Status
*
Full Time
Part Time
Not a Student
Language Spoken
*
Interpreter Needed
*
Yes
No
Housing Status
*
Public Housing
Not Public Housing
Homeless Status
*
Not Homeless
Doubling up
Shelter
Street
Transitional
Other
Migrant/Seasonal Status
*
Not a Migrant or Seasonal Farm Worker
Migrant (within last 24 months had to establish temporary home for purpose of employment in agriculture)
Seasonal (seasonal agricultural worker and has not had to establish temporary home for this employment)
Sexual Orientation
*
Straight (not gat or lesbian)
Lesbian or Gay
Bisexual
Chose not to disclose
Other
Gender Identity
*
Male
Female
Chose not to disclose
Transgender Female to Male
Transgender Male to Female
Other
Race
*
White
Black African-American
More than one race
Other Pacific Islander
Transgender Male to Female
American Indian
Asian
Native Hawaiian
Other
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Veteran Status
*
YES -I am a Veteran
NO - I am not a Veteran
Do you have a LIVING WILL?
*
Yes
No
Other
Responsible Party Information
Relationship to Patient
Self
Spouse
Parent
Other
Name
*
First Name
Middle Name
Last Name
SSN
*
Date of Birth
*
-
Month
-
Day
Year
Date
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Insurance Information (Please give your insurance card to the receptionist)
Health insurance policies may cover a portion of the fees and MCMC staff will assist you in making claims. It is expected that you will inform us of changes in your family status or health insurance coverage. Please fill in the name of your insurance company(s), and sign below. By signing below, I authorize Morgan County Medical Center to assist me in obtaining third party benefits, to file benefit claims on my behalf, and to release any information necessary for the processing of my claim(s) to any of the insurance companies or third-party benefit agents listed below. I understand that such information may include diagnosis, dates of service, types of treatment, results of evaluations/assessments, actual progress notes, and other information about services received. This release shall remain in effect until all claims filed on my behalf have been processed. I authorize and request direct payment of my health insurance benefits to Morgan County Medical Center. This authorization shall apply to all covered health services that I receive at the Center. If requested, I have been provided with a copy of the fee scale.
Patient Name
*
First Name
Last Name
Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Primary Insurance
*
Check here if current card on file
No Insurance
Medicaid/TennCare
Medicare
Other (Employer/Private/Commercial)
Patient's Relationship to Insured
*
Self
Spouse
Child
Other
Plan Name
*
Member ID Number
*
Group Number
*
Effective Date (if known)
-
Month
-
Day
Year
Date
Insured Name
*
First Name
Last Name
Insured SSN
*
Insured Date of Birth
*
-
Month
-
Day
Year
Date
Secondary Insurance
Check here if current card on file
No Insurance
Medicaid/TennCare
Medicare
Other (Employer/Private/Commercial)
Secondary Insurance
Self
Spouse
Child
Other
Plan Name
Member ID Number
Group Number
Effective Date (if known)
-
Month
-
Day
Year
Date
Insured Name
First Name
Last Name
Insured SSN
Insured Date of Birth
-
Month
-
Day
Year
Date
Consent for Evaluation and Treatment
Morgan County Medical Center (MCMC) is dedicated to providing comprehensive primary care and behavioral health services. Because wellness involves both the body and mind, our multidisciplinary team of providers work together to offer you high quality whole person healthcare. In order to provide you with comprehensive and coordinated care, your providers may involve other healthcare specialists as part of your care team. Members of your health care team will collaborate and share clinical information as needed to ensure enhanced continuity of care. Some services at MCMC may involve the use of telemedicine equipment. These services utilize high-speed electronic connections and incorporate healthcare industry-standard encryption and data security methods. While there is no guarantee these transmissions cannot be intercepted, great care is taken to prevent all unlawful access to electronic data. I understand, that if I am 16 years of age or older, I may consent for certain types of health services, including mental health services; if I am 18 years of age or older, I may consent for all other health services; otherwise my parent or legal guardian will need to consent to services. By signing this form, (parent or legal guardian signature, if required) I agree that I have read or had this form read and/or explained to me, that I understand it and that any questions I asked have been answered. I understand that I agree to be truthful in providing information. Thus, I hereby ask, agree, and consent to evaluation and treatment for myself and/or child(ren) as set forth above, including any studies or procedures that MCMC professional staff decide are necessary or appropriate. If signing as parent or guardian, I hereby represent and warrant that I am legally empowered and entitled to make such decisions.
Patient’s or Guardian’s Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Privacy Practices/Patient Rights and Responsibilities
I understand that a copy of MCMC’s Privacy Practices is available upon request.
Patient’s or Guardian’s Signature
*
I understand that a copy of MCMC’s Patient Rights and Responsibilities is available upon request.
Patient’s or Guardian’s Signature
*
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Age 3 and Under Health History
Early Childhood Health History Questionnaire
All questions contained in this questionnaire are strictly confidential and will become part of your child’s medical record
Patient Name
*
First Name
Middle Name
Last Name
Sex at Birth
*
Please Select
Male
Female
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Completed by
*
Relationship to Child
*
Birth History
Complications of pregnancy
*
Yes
No
Complications of delivery
*
Yes
No
NICU stay
*
Yes
No
Weeks of gestation
*
Birth Weight
*
Alcohol/Drug/Cigarette use during pregnancy
*
Medical Issues
Select all that apply
*
Vision Problems
Hearing Problems
Seizures
GI issues, reflux
Allergies, asthma, reactive airway disease
High Fevers
Head Injuries
Broken Bones
Stitches
Hospitalizations
Ear Infections
PE (ear) Tubes
Tonsils/Adenoids removed
Other Surgeries
Other medical issues
Please explain items checked above
*
Immunization History
Are immunizations up to date?
*
Yes
No
Has patient received immunizations elsewhere?
*
Yes
No
If yes, where
Current Medications
Rows
Medication
When Started
Purpose
Medication One
Medication Two
Medication Three
Medication Four
Surgeries and Hospitalizations
Rows
Type of SURGERY and Reason for Surgery
Year
Hospital Name
Surgery One
Surgery
Two
Surgery
Three
Surgery
Four
Rows
Type of HOSPITALIZATIONS for ILLNESSES (include reason)
Year
Hospital Name
Hospitalization
One
Hospitalization
Two
Hospitalization
Three
Hospitalization
Four
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Name
*
First Name
Last Name
Date of Birth
*
Child currently lives with
Is your child affectionate?
*
Yes
No
Does you child seem to be able to read your feelings and show empathy?
*
Yes
No
Do you think your child makes good eye-contact?
*
Yes
No
Does your child smile at you?
*
Yes
No
Does your child play peek-a-boo or patty cake?
*
Yes
No
Does your child show you things that interest him or her?
*
Yes
No
Does he/she want you to join him/her when he/she is enjoying something?
*
Yes
No
Does your child ask for help?
*
Yes
No
How:
Does your child imitate things you do?
*
Yes
No
Give examples:
Sleeping
Does your child have trouble falling asleep?
*
Yes
No
Does your child have trouble staying asleep?
*
Yes
No
How many hours of sleep per night (give a range if variable)
*
Eating
Are there eating difficulties?
*
Yes
No
Does your child eat at least 20 different foods including at least 2 fruits and 2 vegetables?
*
Yes
No
Has your child had intervention (like feeding therapy) for problems eating?
*
Yes
No
How much caffeine (sweet tea, soft drinks, coffee, etc.) does your child drink per day:
Self-Care
Is your child toilet trained?
*
Yes
No
Does your child cooperate with toilet training?
*
Yes
No
Does your child cooperate with other self-care tasks such as dressing, bathing and brushing teeth?
*
Yes
No
Developmental History
Do you think your child was delayed in reaching early motor milestones, like sitting, crawling, walking?
*
Yes
No
At what age did your child walk
Do you think gross motor (arm and leg) skills are up to age level?
*
Yes
No
Do you think fine motor (finger) skills are up to age level?
*
Yes
No
Behavioral Issues
Does your child seem anxious?
*
Yes
No
Unusual fears:
More than average afraid of:
*
The dark
Storms
Strangers
Bugs, bees
New places
Changes in routine
What does your child do when angry?
*
Yell, cry, scream
Hit, kick, bite others
Drop to floor, go limp
Self-injury
Throw things
Other
On average, how long do outbursts last (up to 5 minutes, 30 minutes, etc):
How long are the worst outbursts:
How often do the outbursts occur (daily, weekly, monthly):
What triggers outbursts:
What do you do when your child is having outbursts:
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Name
*
First Name
Last Name
Date of Birth
*
Sensory Processing
Does your child currently have sensory issues (overly sensitive or overly absorbed):
*
Rows
Yes
No
Describe
Vision (stares at things a long time)
Auditory (covers ears, bothered by noise)
Tactile (distraught when messy)
Taste (avoids food textures)
Smell (gags w/ odor, sniffs things)
Pain tolerance, high or low
Does your child engage in any stereotyped or repetitive motor mannerisms?
Arm Flapping
Finger Flicking
Lining up Objects
Spinning
Rocking
Describe:
Any other sensory concerns?
Language Development
Is there another language spoken in the home besides English?
*
Yes
No
If Yes, what language:
Age at first word:
Example:
Is your child’s vocabulary up to age level?
*
Yes
No
Estimated vocabulary size:
Do you think fine motor (finger) skills are up to age level?
*
Yes
No
How does your child request:
*
Gesture
Point
Lead to
Bring
Sign
Tantrum
Words
Sentence
Give Examples
Was there ever a time when their language skills regressed or were lost?
*
Yes
No
If Yes, describe
Can your child follow one step directions (Let’s go eat? Let’s go bye bye?):
*
Yes
No
Can your child follow a direction to “go get” something:
*
Yes
No
Does your child respond when you call his/her name:
*
Yes
No
Does your child understand the word “no”:
*
Yes
No
Can your child point to body parts named:
*
Yes
No
Can your child answer “What’s your name?”:
*
Yes
No
Can your child answer yes/no questions reliably:
*
Yes
No
Can your child answer when a peer asks “What’s your name?”:
*
Yes
No
Does your child echo/repeat meaningless phrases heard?
*
Yes
No
If Yes, describe
Does your child say the same word or phrase over and over:
*
Yes
No
If Yes, describe
Does your child mix up pronouns (I, you, me, he, she):
*
Yes
No
If Yes, describe
Does your child quote phrases from movies or TV shows:
*
Yes
No
If Yes, describe
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Name
*
First Name
Last Name
Date of Birth
*
Intervention
Does/did your child receive TEIS services:
*
Yes
No
Does/did your child attend preschool or daycare:
*
Yes
No
If Yes, where:
Teacher Name
Language therapy:
*
Yes
No
Occupational therapy:
*
Yes
No
Physical therapy:
*
Yes
No
Social Functioning With Peers
Does your child show an interest in others the same age:
*
Yes
No
Does your child watch other children at play:
*
Yes
No
With peers, can your child join chase games?
*
Yes
No
With peers, can your child join ball play?
*
Yes
No
With peers, can your child join imitation (copy cat) play?
*
Yes
No
Play Interests
Does your child show an interest in:
*
Balls
Toy Cars
Blocks, legos
Figurines
Books
Tech toys
How much screen time does your child have per day (TV, tablets, video games, phones, etc.):
*
Does your child pretend to:
*
Talk on a phone
Be an animal, like a cat or dinosaur
Cook or play doctor
Does your child have any unusual interests:
*
What are your child's favorite toys or activities:
*
Does your child seem absorbed or “obsessed” by any objects or activities:
*
Yes
No
If Yes, describe
What are your child’s strengths:
*
Is there anything else that you would like for us to know about your child that we did not ask:
*
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Name
*
First Name
Last Name
Date of Birth
*
HIPAA Authorization
Keeping our patient’s information private is important and by default we will only disclose information related to your medical information including labs and test results, diagnosis, and treatment to the patient or legal guardian. However, if you would like to add other contacts that you would like for Morgan County Medical Center (MCMC) to disclose this information please complete the fields below:
Contact Name
First Name
Last Name
Relationship to Patient (Spouse, Child, etc.):
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Name
First Name
Last Name
Relationship to Patient (Spouse, Child, etc.):
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Name
First Name
Last Name
Relationship to Patient (Spouse, Child, etc.):
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
The duration of this authorization is indefinite unless otherwise changed in writing. MCMC understands that requests for health information from persons not listed on this form will require your specific authorization prior to the disclosure of any health information.
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