New Patient Questionnaire with Health History

FRED CO KIDS

New Parent Questionnaire

*This form is detailed and may take 5-10 minutes to complete.

I. GENERAL INFORMATION

Do you have a children currently a patient(s) at our practice?

Yes. Name of sibling that is a current patient:

Name of person providing information on this form

Baby's expected due date

Date

Where do you plan to deliver?

Baby's Insurance (Name of Insurance Carrier)

Policy Holder Insurance Member ID

Name of Policy Holder of Insurance

Policy Holder's Date of Birth

Date

Are parents/guardians of child currently:

If separated or divorced, who has legal custody (specify):

Who will your child live with?

Race / ethnicity of child:

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

Date

Parent / Caregiver #1 Cell phone

Please enter a valid phone number.Format: (000) 000-0000.

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

Date

Parent / Caregiver #2 Cell phone

Please enter a valid phone number.Format: (000) 000-0000.

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 expected 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?

Yes. Please specify which language(s):

What type of child care will you use?

Do you have any pets?

Yes. Please list what type(s):

Does anyone in the family smoke in or around the home?

Are there any guns present in your home?

If yes, are they kept locked away?

What is the fluoride status of your home?

Any known health concerns for this baby?

Family History - Have any of your child's parents, grandparents, aunts, uncles, brothers, or sisters ever had any of the following conditions? Please specify maternal or paternal side.

Family History of Allergies