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?*

NoYes. Name of sibling that is a current patient:
Name of person providing information on this form*
Baby's expected due date*

MonthDayYear
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*

MonthDayYear
Date
Are parents/guardians of child currently:*

MarriedSeparatedDivorcedNever married
If separated or divorced, who has legal custody (specify):
Who will your child live with?*

Both parentsMotherFatherAdoptive ParentsFoster ParentsOther (please specify)
Race / ethnicity of child:

AsianBlack/ African AmericanOtherWhiteHispanic/ LatinoMore than one raceDo 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 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?

NoYes. Please specify which language(s):
What type of child care will 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
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*

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.*
Did you attend the FCP Prenatal Meet and Greet?*

YesNo
If yes, when?

MonthDayYear
Date
Should be Empty: