New Patient Questionnaire with Health History

FRED CO KIDS

New Patient Questionnaire

*This form is detailed and may take 15-20 minutes to complete. Please fill out one per child.

I. GENERAL PATIENT INFORMATION
Does this child have a sibling currently a patient at our practice?*

NoYes. Name of sibling that is a current patient:
Child's Full Name*

First NameLast Name
First Name Used (Nickname)
Child's Date of Birth*

MonthDayYear
Date
Grade in school, if applicable
Assigned Sex at Birth*
Gender Identity (She, he, them, other)
Pronouns Used (She, he, them, other)
Name of person providing information on this form*
Child's Insurance (Name of Insurance Carrier)*
Child's Insurance Member ID*
Name of Policy Holder of Insurance*
Policy Holder's Date of Birth*

MonthDayYear
Date
Are parents/guardians of child currently:*

MarriedSeparatedDivorcedNever married
If separated or divorced, who has legal custody (specify):*
**If a custody order exists, please email it to info@fredcokids.com to place in the patient's chart
Who does your child live with?*

Both parentsMotherFatherAdoptive ParentsFoster ParentsOther (please specify)
Race / ethnicity of child (May select more than one):*

AsianBlack/ African AmericanWhiteHispanic/ LatinoOtherDo not want to disclose
Parent / Caregiver #1 Full Name*

First NameLast Name
Parent / Caregiver #1 preferred pronouns (she, he, them, other)
Parent / Caregiver #1 relationship to child*
Parent / Caregiver #1 Date of Birth*

MonthDayYear
Date
Parent / Caregiver #1 Cell phone*
Please enter a valid phone number.
Parent / Caregiver #1 Email*
example@example.com
Parent / Caregiver #1 preferred parental name (Mom, Mommy, Dad, Papa, ......)
Parent / Caregiver #1 Home/ Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent / Caregiver #1 Race/Ethnicity
Parent / Caregiver #2 Full Name

First NameLast Name
Parent / Caregiver #2 preferred pronouns (she, he, them, other)
Parent / Caregiver #2 relationship to child
Parent / Caregiver #2 Date of Birth

MonthDayYear
Date
Parent / Caregiver #2 Cell phone
Please enter a valid phone number.
Parent / Caregiver #2 Email
example@example.com
Parent / Caregiver #2 preferred parental name (Mom, Mommy, Dad, Papa, ......)
Parent / Caregiver #2 Home/ Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent / Caregiver #2 Race/Ethnicity
Does your child have any siblings? # of sisters:
# of brothers:
# of nonbinary:
Have there been any significant changes in the home over the last few years? (Such as new marriages, deaths, births, address changes, family separations/divorce, parent dating, parent job change, financial hardship, etc)
Primary language spoken in the home*
Any other languages spoken in the home?*

NoYes. Please specify which language(s):
What type of child care do you use?*

NoneRelativePrivate sitterDaycare/Preschool
Do you have any pets?*

NoYes. Please list what type(s):
Does anyone in the family smoke in or around the home?*

YesNo
Are there any guns present in your home?*

NoYesIf yes, are they kept locked away?
What is the fluoride status of your home?*

FluoridatedNon-fluoridated (well water)Unknown
Does your child see a dentist?*

YesNo
Does your child have a history of dental issues? (multiple cavities, etc.)*

NoYes. Please specify:
II. HEALTH AND DEVELOPMENT

A. Pregnancy and Birth History
Type of delivery

VaginalC-section
Gestational age in # of weeks
Birth Weight
Please list any complications related to the pregnancy/birth
Past Medical History - Has your child ever had any of the following problems? Serious Illness*

NoYes. Please provide details & when:
Head Injuries*

NoYes. Please provide details & when:
Seizures/Convulsions*

NoYes. Please provide details & when:
History of Frequent Ear Infections*

NoYes. Please provide details & when:
Asthma/Reactive Airway Disease*

NoYes. Please provide details & when:
History of Pneumonia or RSV*

NoYes. Please provide details & when:
Seasonal /Indoor Allergies*

NoYes. Please provide details & when:
Eye /Vision Problems*

NoYes. Please provide details & when:
Ear /Hearing Problems*

NoYes. Please provide details & when:
Heart Conditions*

NoYes. Please provide details & when:
High Blood Pressure*

NoYes. Please provide details & when:
Skin Problems / Eczema*

NoYes. Please provide details & when:
Kidney Conditions / UTIs / Bladder Infections*

NoYes. Please provide details & when:
Bedwetting (after 6 years old)*

No or N/AYes. Please provide details & when:
Diabetes*

NoYes. Please provide details & when:
Thyroid / Other Endocrine Problems*

NoYes. Please provide details & when:
Metabolic / Genetic Disorders*

NoYes. Please provide details & when:
GI Concerns / Constipation / Food Intolerances*

NoYes. Please provide details & when:
Anemia / Bleeding Disorders*

NoYes. Please provide details & when:
Cancer*

NoYes. Please provide details & when:
Immunocompromised (transplant, asplenia, etc.)*

NoYes. Please provide details & when:
Developmental Delay (Speech or Motor)*

NoYes. Please provide details & when:
School Problems / Learning Disabilities*

No or N/AYes. Please provide details & when:
ADHD / Behavioral Concerns*

NoYes. Please provide details & when:
Anxiety / Depression / Mood Problems*

NoYes. Please provide details & when:
Sleep Problems*

NoYes. Please provide details & when:
Tobacco / Alcohol / Drug Use*

NoYes. Please provide details & when:
Sexually Transmitted Infections*

No or N/AYes. Please provide details & when:
Other Infectious Diseases (Tuberculosis, CMV, Mononucleosis, HIV, etc.)*

NoYes. Please provide details & when:
Exposure to Abuse / Family Violence*

NoYes. Please provide details & when:
Bone / Joint Injuries*

NoYes. Please provide details & when:
Bone / Joint Conditions*

NoYes. Please provide details & when:
Overweight / Obesity*

NoYes. Please provide details & when:
Underweight / Eating Concerns*

NoYes. Please provide details & when:
Other Health Problem*

NoYes. Please provide details & when:
Is your child currently taking any daily medication(s)?*

NoYes. Please list name(s) of medication, dose(s) and purpose for each medication:
Does your child have any allergies to medications or foods?*

NoYes. Please provide details:
Has your child been seen in the ER in the last year?*

NoYes. Please explain:
Has your child had any surgeries or hospitalizations?*

NoYes. Please explain:
Does your child see any specialists?*

NoYes. Please list what for and who do they see:
Has your child ever received psychological counseling?*

NoYes. Please list by whom and when:
Family History - Have any of your child's parents, grandparents, aunts, uncles, brothers, or sisters ever had any of the following conditions? Please specify specific relation (i.e. maternal grandmother or paternal grandfather).
Family History of Allergies*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Asthma / Lung Disease*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Genetic Disorders / Birth Defects*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Seizures / Epilepsy*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Heart Attack*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Stroke

NoYes. Please provide details and specify maternal or paternal side:
Family History of Sudden Death (before age 50)*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Other Heart Disease*

NoYes. Please provide details and specify maternal or paternal side:
Family History of High Blood Pressure*

NoYes. Please provide details and specify maternal or paternal side:
Family History of High Cholesterol*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Obesity*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Blood Disorders / Sickle Cell*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Kidney Disease*

NoYes. Please provide details and specify maternal or paternal side:
Family History of GI / Digestive Conditions*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Diabetes*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Thyroid / Endocrine Disease*

NoYes. Please provide details and specify maternal or paternal side:
Family History of HIV/ AIDS*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Other Infectious Diseases (Tuberculosis, CMV, etc.)*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Hearing Loss*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Cancer (before 55 years old)*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Hepatitis / Liver Disease*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Developmental Disability*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Learning Problems / ADHD*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Depression / Anxiety*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Other Mental Illness*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Alcohol / Drug Abuse*

NoYes. Please provide details and specify maternal or paternal side:
Family History of Family Violence*

NoYes. Please provide details and specify maternal or paternal side:
Family History of any Other Health Condition*

NoYes. Please provide details and specify maternal or paternal side:
Do you have any concerns that you were hoping to address at your child's first visit? If yes please explain below. Depending on the complexity of your concern, we may need more than one appointment.*
Should be Empty:

**If a custody order exists, please email it to info@fredcokids.com to place in the patient's chart