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 today? (¿Cuál es el motivo de la visita de su hijo/a hoy?)*
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 delHigado/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 the patient's primary insurance information. Please be aware that our office does not bill or accept secondary insurance.
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