New Patient Questionnaire

New Patient Questionnaire / Cuestionario Para Paciente Nuevo
Patient Name/Nombre del Paciente: *

First NameLast Name
Date of Birth/Fecha de Nacimiento: *

MonthDayYear
Date
Today’s Date/Fecha:

MonthDayYear
Date
What is the reason for your child 's visit? (¿Cuál es el motivo de la visita de su hijo?)*
Who is your child's primary care physician? (¿Quien es su doctor de cabecera?) *
Name and/or clinic address (Nombre/direcion de clinica
Additional information (adicional):

Developmental delay (retraso en el desarrollo)Poor growth (pobre crecimiento)Depressed mood(animo deprimido)ADHD/Hyperactivity(TDAH/hiperactividad)Anxiety (ansiedad)Diabetes(diabetes)Thyroid problems(problemas de tiroidesDown Syndrome(sindrome de down)Autism(autismo)Other
Please CHECK any of the following symptoms that your child has (Favor de marcar cualessintomas su hijo/a tiene) :

Weight Change (cambio de peso)Chest pain (dolor de pecho)Heartburn(acides)NauseaVomiting (vomito)Abdominal Pain (dolor abdominal)Poor appetite (apetito bajo)DiarrheaFatigue(cansancio)Constipation(estrefiimiento)Reflux(reflujo)Blood in vomit(sangre en el vomito)Cough(tos)AnemiaBlood in urine (sangre al orinar)Coughing up blood (sangrado al toser)Blood in stool(sangre en la popo)Jaundicelyellowing of skin (ictericia/amarillento de la piel)Apnea/stops breathing (apnea/deja de respirar)Trouble swallowing (dificultad al pasarse comida)Shortness of breath(dificultad para respirarLiver Problems or Hepatitis (problemas del Higado/Hepatitis)

List all current medications. Please include over the counter, herbal therapies and vitamins. (Anote todos los medicamentos que su hijo/a toma. Incluya medicamentos sin receta, terapias a base de hierbas o vitaminas):

	Current Medication (nombre del medicamento)	Dose (Dosis)	How often (frecuencia)
1
2
3
4

1. List any known medical problems your child has. (ie, asthma, reflux, Crohn’s, diabetes, etc.) Anote otros problemas médicos que su hijo/a tenga. (ex. asma, enfermedad de Crohn, diabetes, etc.) *



2. Allergies to any Food/Medication (Alergias a comida o medicamento): *
3. Family History of Liver/Pancreas problems, Celiac disease, IBD (UC or Crohn’s), IBS, Autoimmune disease. (Historial familiar de problemas de Higado/Péncreas, enfermedad celiaca, enfermedad intestinal inflamatoria, colitis ulcerosa, enfermedad de Crohn, enfermedad autoinmune) *
4. Is your child on a special/restricted diet? (¢Esta su hijo/a una dieta especial/restringida?) -*
Stooling History (Historial al defecar si es pertinente):
How often does your child have a bowel movement now? (Qué tan frecuente hacepopo su hijo/a): *
Does your child have accidents/soil underpants? (Su hijo/a tiene accidentes/manchasus calzoncillos?) *
What is the consistency of your child 's stool? (;Cuél es la consistencia de la popode su hijo/a?)

Watery(aguada)Soft (suave)Hard (dura)Pebbles (bolitas)
What is the color of your child 's stool?

Brown(cafe)Yellow(amarilla)Green(verde)Red(roja)Black (negra)
6. Does your child see any other specialist? (Su hijo/a ve algan otro especialista?)
Parent Signature/Firma de madre o padre: *

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Patient's Demographics

New Patient Form
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Parent/Guardian's Full Name*

First NameLast Name
Relationship to Patient*
Email Address*
example@example.com
Primary phone contact*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Information

In case of emergency, please provide the contact information for someone not living with the patient.
Emergency Contact's Full Name*

First NameLast Name
Emergency Contact's Phone Number*
Please enter a valid phone number.
Relationship to Patient*
Insurance Information

Please provide all and any insurance cards that the patient's has. Please be aware that our office does not bill or accept secondary insurance. Our office will be able to determine which of your insurance plans is considered the primary insurance. Please call our office if you need help filling in this information
Insurance Provider*
Policy Number*
Group Number*
Upload picture of insurance card front and back*

Cancelof
Upload parent's drivers license*

Cancelof
Date

MonthDayYear
Date
Signature*

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Should be Empty:

New Patient Questionnaire / Cuestionario Para Paciente Nuevo

Patient's Demographics

Emergency Contact Information

Insurance Information