Registration Form
Patient's Information
Age
Date of birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Today's Date
-
Month
-
Day
Year
Date
Child's Name
Hospital of birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Pharmacy of Choice
Mother's Information
Name
Cell Phone
-
Area Code
Phone Number
Address
SS#
Date of birth
-
Month
-
Day
Year
Date
Employer
Business Phone
Please enter a valid phone number.
Father's Information
Name
Cell Phone
-
Area Code
Phone Number
Address
SS#
Date of birth
-
Month
-
Day
Year
Date
Employer
Business Phone
Please enter a valid phone number.
Insurance Information
Name of Insurance
(Please provide a copy of your card)
Browse Files
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Choose a file
Cancel
of
Policy Holder
Policy Number
Group
Secondary Insurance
(Please provide a copy of your card)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Policy Number
Policy Holder
Group
Back
Next
Columbus Children's Healthcare
Patient Name
Person to receive bills
Father
Mother
Other
Name
Relationship to Child
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Person to contact In case of an emergency.
This should be someone other than a parent.
Name
Relationship to Child
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Please list all persons living in the same house as the child and their relationship to the child.
Pregnancy and Birth:
Please answer the following questions related to the mother's pregnancy and child's birth. If you answer yes, please explain.
Were there arty problems during the mother's pregnancy?
Yes
No
If yes, please explain.
Did the mother use any cigarettes, alcohol, recreational drugs or medications during her pregnancy?
Yes
No
If yes, please explain.
Did the baby come more than 2 weeks early or 2 weeks late?
Yes
No
If yes, please explain.
What was the baby's birth weight?
Were there any problems during labor or delivery?
Yes
No
If yes, please explain.
Delivery was
Vaginal
Section
Were there any problems with the baby daring the stay in the hospital nursery?
Yes
No
If yes, please explain.
Have any of the child's brothers or sisters died?
Yes
No
If yes, please explain
ALLERGIES-Please list all of the child's allergies, Including any allergic reactions to drugs:
FAMILY HISTORY
Check any illnesses that the child or members of the child's family have had:
Child
Family
Frequent Ear Infections
Frequent Colds/Sore Throats Croup
Mumps, Measles, Chicken Pox
Wheezing/Asthma
Pneumonia
Eye Problems
Dental Problems
Hearing Problems
Hay Fever/Seasonal Allergies
Emotional Disorders/Suicide Attempt Anemia/Blood Problems
Diabetes
Kidney/Bladder Problems
Seizures/Convulsions
Early Heart Disease
High Cholesterol
High Blood Pressure
Lung Disease/Tuberculosis
Sexually Transmitted Disease
Alcohol/Drug use
Cancer Eczema/Skin Problems
Other Illnesses:
DEVELEPMENT AND BEHAVIORAL ISSUES
Old the child sit alone by 7 months?
Yes
No
Did the child walk alone by 14 months?
Yes
No
Did the child say 3 words by 15 months?
Yes
No
Is the child doing well in school?
Yes
No
Does the child get along with other children?
Yes
No
Select any of the following which the child has:
Nightmares/Sleep Problems
Thumb Sucking
Irritable/Bad Temper
Bed Wetting
Toilet Training Problems
Speech issues
Discipline Problems
Breath Holding
HEALTH AND SAFETY ISSUES
Are there any guns in the child's house?
Yes
No
Does the child use a toothbrush daily?
Yes
No
Does the child use a car seat or seatbelt all of the time?
Yes
No
Are there smoke detectors In the home?
Yes
No
Is the hot water temperature less than 12E?
Yes
No
Do you or someone In the household know CPR?
Yes
No
HOSPITALIZATIONS OR SERIOUS AND/OR UNUSUAL ILLNESSES:
SIBLINGS: Please list the names and birth dates at all siblings:
Pharmacy of Choice
Communication Preference:
Home Phone
Cell Phone
Work Phone
Letter
Email
Email Address
example@example.com
Due to new Healthcare Regulations, please answer the following questions.
Race
Primer/ Language Spoken in Household
Submit
Should be Empty: