Today's date:
AZIZ IMTIAZ M.D.
PATIENT INFORMATION
Name
First Name
Middle Initial
Last Name
Title
Miss
Mrs.
Mr.
Born in the USA?
Yes
No
Birth Place:
Date of Birth
-
Month
-
Day
Year
Date
Age:
Sex:
M
F
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number:
Cellphone
Format: (000) 000-0000.
Occupation
Employer:
Employer No.:
How did you find us?
Internet
Familiar
Insurance plan
Other
PARENT(S) INFORMATION
Mother Name
Date of birth.:
-
Month
-
Day
Year
Date
Address (if different):
Telephone No.:
Format: (000) 000-0000.
Occupation:
Employer:
Employer Address:
Social Security #:
Father Name
Date of birth:
-
Month
-
Day
Year
Date
Address (if different):
Home phone no.:
Format: (000) 000-0000.
Occupation:
Employer:
Employer Address:
Social Security #:
INSURANCE INFORMATION
Primary Insurance Name:
Subscriber name:
ID #
Name of secondary insurance (if applicable):
Subscriber name:
ID #
IN CASE OF EMERGENCY
Name of friend/relative (who does not live at the same address):
Relationship to the patient:
Telephone number:
Format: (000) 000-0000.
Work Number
Format: (000) 000-0000.
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the doctor. I understand that I am responsible for any balance not covered by my insurance. I also authorize [PM Pediatrics] or the insurance company to release all information necessary to process my claims.
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Signature of patient/guardian
Date
-
Month
-
Day
Year
Date
Being Web enabled will allow you to:
Change and make appointments for your child
View vaccines received in our office
View the medical summary of all your child's visits (Diagnosis, medication given, etc.)
Receive educational articles about your child's diagnosis, medication, or vaccines
And much more!
Yes, I would like to be web-enabled
Email:
example@example.com
No, at this time I do not want to be web-enabled.
****Keep in mind that you can apply for this program at any time. **
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PM
PEDIATRICS, P.A.
Name
birthdate
M F
M
F
Previous doctor:
Date of last physical exam:
PERSONAL HEALTH HISTORY
List any medical problems that other doctors have diagnosed
Surgeries
Surgeries
Rows
Year
Reason
Hospital
1
2
3
4
5
Other hospitalizations
Other hospitalizations
Rows
Year
Reason
Hospital
1
2
3
4
5
Have you ever received a blood transfusion?
Yes
No
Please turn to next page
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List your prescription and over-the-counter medications, such as vitamins and inhalers
Rows
Name the drug
MG
Frequency taken
1
2
3
4
5
6
7
8
Drug allergies
Rows
Name the drug
Reaction:
1
2
3
FAMILY HEALTH HISTORY
FAMILY HEALTH HISTORY
Rows
AGE
AGE
SIGNIFICANT HEALTH PROBLEMS
AGE
SIGNIFICANT HEALTH PROBLEMS
1
2
3
4
5
6
7
8
CURRENT HEALTH PROBLEMS
Please check if you have or have had any symptoms in the following areas to a significant degree and explain briefly
Fur
Chest/Heart
Recent changes to:
Head/Neck
Back
Weight
Ears
Intestinal
Power level
Nose
Bladder
ability to sleep
Throat
Intestine
Other pain/discomfort:
Lungs
Circulation
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PM PEDIATRICS, P.A.
I
the parent/guardian of
Date
-
Month
-
Day
Year
Date Picker Icon
of Birth
-
Month
-
Day
Year
Date Picker Icon
authorize the following people to take my child to the doctor's office in a case where he or she is unable to:
Relationship with the patient
1.
2.
3.
4.
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