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 that is currently a patient at our practice?*

NoYes. Name of sibling that is a current patient:
Name of person providing information on this form*
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)
Race / ethnicity of child (May select more than one):*

AsianBlack/ African AmericanWhiteHispanic/ LatinoOtherDo not want to disclose
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):

MotherFatherOther, please specify:
**If a custody order exists, we require a copy for your child's chart. Without it, all parents are allowed equal access to information and decision-making. Please email a copy to info@fredcokids.com**
Is there any sensitive information pertaining to custody or family dynamic that you request not be discussed in front of your child?*

NoYes, please specify:
Who does your child live with?*

Both parentsMotherFatherAdoptive ParentsFoster ParentsRelatives (specify below)Other (please specify)
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

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 diagnosis/details:
Head Injuries*

NoYes. Please provide diagnosis/details:
Seizures/Convulsions*

NoYes. Please provide diagnosis/details:
History of Frequent Ear Infections*

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

NoYes. Please provide diagnosis/details:
History of Pneumonia or RSV*

NoYes. Please provide diagnosis/details:
Seasonal /Indoor Allergies*

NoYes. Please provide diagnosis/details:
Eye /Vision Problems*

NoYes. Please provide diagnosis/details:
Ear /Hearing Problems*

NoYes. Please provide diagnosis/details:
Heart Conditions*

NoYes. Please provide diagnosis/details:
High Blood Pressure*

NoYes. Please provide diagnosis/details:
Skin Problems / Eczema*

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

NoYes. Please provide diagnosis/details:
Bedwetting (after 6 years old)*

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

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

NoYes. Please provide diagnosis/details:
Metabolic / Genetic Disorders*

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

NoYes. Please provide diagnosis/details:
Anemia / Bleeding Disorders*

NoYes. Please provide diagnosis/details:
Cancer*

NoYes. Please provide diagnosis/details:
Immunocompromised (transplant, asplenia, etc.)*

NoYes. Please provide diagnosis/details:
Developmental Delay (Speech or Motor)*

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

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

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

NoYes. Please provide diagnosis/details:
Sleep Problems*

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

NoYes. Please provide diagnosis/details:
Sexually Transmitted Infections*

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

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

NoYes. Please provide diagnosis/details:
Bone / Joint Injuries*

NoYes. Please provide diagnosis/details:
Bone / Joint Conditions*

NoYes. Please provide diagnosis/details:
Overweight / Obesity*

NoYes. Please provide diagnosis/details:
Underweight / Eating Concerns*

NoYes. Please provide diagnosis/details:
Other Health Problem*

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

NoYes. Please list medications:
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 relationship to child:
Family History of Asthma / Lung Disease*

NoYes. Please provide details and relationship to child:
Family History of Genetic Disorders / Birth Defects*

NoYes. Please provide details and relationship to child:
Family History of Seizures / Epilepsy*

NoYes. Please provide details and relationship to child:
Family History of Heart Attack*

NoYes. Please provide details and relationship to child:
Family History of Stroke

NoYes. Please provide details and relationship to child:
Family History of Sudden Death (before age 50)*

NoYes. Please provide details and relationship to child:
Family History of Other Heart Disease*

NoYes. Please provide details and relationship to child:
Family History of High Blood Pressure*

NoYes. Please provide details and relationship to child:
Family History of High Cholesterol*

NoYes. Please provide details and relationship to child:
Family History of Obesity*

NoYes. Please provide details and relationship to child:
Family History of Blood Disorders / Sickle Cell*

NoYes. Please provide details and relationship to child:
Family History of Kidney Disease*

NoYes. Please provide details and relationship to child:
Family History of GI / Digestive Conditions*

NoYes. Please provide details and relationship to child:
Family History of Diabetes*

NoYes. Please provide details and relationship to child:
Family History of Thyroid / Endocrine Disease*

NoYes. Please provide details and relationship to child:
Family History of HIV/ AIDS*

NoYes. Please provide details and relationship to child:
Family History of Other Infectious Diseases (Tuberculosis, CMV, etc.)*

NoYes. Please provide details and relationship to child:
Family History of Hearing Loss*

NoYes. Please provide details and relationship to child:
Family History of Cancer (before 55 years old)*

NoYes. Please provide details and relationship to child:
Family History of Hepatitis / Liver Disease*

NoYes. Please provide details and relationship to child:
Family History of Developmental Disability*

NoYes. Please provide details and relationship to child:
Family History of Learning Problems / ADHD*

NoYes. Please provide details and relationship to child:
Family History of Depression / Anxiety*

NoYes. Please provide details and relationship to child:
Family History of Other Mental Illness*

NoYes. Please provide details and relationship to child:
Family History of Alcohol / Drug Abuse*

NoYes. Please provide details and relationship to child:
Family History of Family Violence*

NoYes. Please provide details and relationship to child:
Family History of any Other Health Condition*

NoYes. Please provide details and relationship to child:
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, we require a copy for your child's chart. Without it, all parents are allowed equal access to information and decision-making. Please email a copy to info@fredcokids.com**

Past Medical History - Has your child ever had any of the following problems?

If a custody order exists, we require a copy for your child's chart. Without it, all parents are allowed equal access to information and decision-making. Please email a copy to info@fredcokids.com