New Pediatric Patient Registration Form

New Patient

PEDIATRIC REGISRATION
Patient Information

Please answer each question to the best of your knowledge.
Patient Name*

First NameMiddle NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date of Evaluation*

YearMonthDay
Date
Referred By:*

First NameLast Name
Parent/ Guardian Name*

First NameLast Name
Parent Email Address*
example@example.com
Primary Language Spoken*

EnglishSpanishOther
Patient Sex*
Primary Concern for Appointment*

Sick VisitInjurySore throat, ear painFeverVomitingBothFollow up
Medical History

Please complete each question to the best of your knowledge.
Pediatrician's Name*

First NameLast Name
What is the name of the hospital where the patient was born?*
What was the mother's length of pregnancy with the patient?*

37-40 weeks30-36 weeks25-29 weeks25 < weeks
Was the mother's labor:*

SpontaneousInducedVaginalC-Section
If yes, which medications or drugs were used?*
Patient's birth weight (pounds)*
Did any of the following complications apply at time of birth?*

JaundiceProlonged Stay at NICULow birth weightBlue colorRespiratory DifficultiesSucking/Swallowing difficultiesInfection of baby or motherBreech BirthFailed NBHSNuchal CordAIDS/ HIVHeart/CardiovascularLow APGAR SCORECMVNone of theseOther
Has the patient experienced any of the following medical complications?*

AIDS/HIVAutismAsthmaAllergy/Sinus ProblemsDevelopmental DelayShort Attention SpanMeaslesTonsilitisScarlet FeverGastrointestinal ProblemsADHD/ ADDBlood DisorderCancerChicken PoxGenetic DisordersDiabetesInfluenzaMeningitisMalariaSpeech DelayEndocrine System DisorderPhysical ImpairmentHeadachesHead InjuryHearing LossHeart ProblemsEar InfectionsBehavioral DisorderVision lossUTIStrokeNeurologic DisorderLearning DisabilityNone of these
Additional Medical History/Symptoms*
Is the patient currently taking any medication?*

YesNo
If yes, please list it here or enter none*
If yes, please list all food allergies.
Academic History
If so, what school does the patient attend?*
What grade is the patient currently in?*
Type a question*
*
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Telemedicine Consult
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Contact Info

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New Patient

Patient Information

Medical History

Academic History