BH - NEW PATIENT QUESTIONNAIRE
I. GENERAL PATIENT INFORMATION
Sibling at our practice?
No
Name:
Child's full name
First Name
Last Name
First Name Used
First Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade
Assigned Sex at Birth
Gender Identity
Pronouns Used
Person providing information
First Name
Last Name
Child's Insurance (Name of Insurance Carrier)
Child's Insurance Member ID
Name of Policy Holder of Insurance
First Name
Last Name
Policy Holder's DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are parents / guardians of child currently:
Married
Separated
Divorced
Never married
If separated or divorced, who has legal custody?
Mother
Father
Other
Who does your child live with?
Both parents
Mother
Father
Adoptive Parents
Foster Parents
Other
Race / ethnicity of child:
Asian
Black/African American
Other
White
Hispanic / Latino
More than one race
Do not want to disclose
More than one race Do not want to disclose
Rows
Parent/ Guardian/ Caregiver #1
Parent/ Guardian/ Caregiver #2
Name
Preferred pronouns (she, he, them, etc.)
Relationship to child
Date of birth
Cell phone #
Email address
Home / Mailing Address
Race / Ethnicity
sisters
brothers
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?
No
Specify:
Does your child see a dentist?
Yes
No
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Does your child have a history of dental issues? (multiple cavities,etc)
No
Yes
Other
II. HEALTH AND DEVELOPMENT
A. Pregnancy and Birth History
Type of Delivery?
Vaginal
C-Section
Gestational Age: _____ weeks
Birth Weight:
Please list any complications related to the pregnancy/birth:
Past Medical History - Has your child ever had any of the following problems?
Rows
No
Yes
Details & when?
Serious Illnesses
Head Injuries
Seizures/convulsions
History of Frequent Ear Infections
Asthma/Reactive Airway Disease
History of pneumonia or RSV
Seasonal/Indoor Allergies
Eye/Vision Problems
Ear/Hearing Problems
Heart Conditions
High Blood Pressure
Skin Problems/Eczema
Kidney Conditions/UTIs/Bladder Infections
Bedwetting (after age 6 years old)
Diabetes
Thyroid/Other Endocrine problems
Metabolic/Genetic Disorders
GI concerns/Constipation/Food intolerances
Anemia/Bleeding problems
Cancer
Immunocompromised (transplant, asplenia, etc.)
Developmental Delay (speech or motor)
School Problems/Learning Disabilities
ADHD//Mood/Behavioral concerns
Anxiety/Depression
Sleep Problems
TobacSeco/Alcohol/Drug Use
Sexually Transmitted Infections
Other Infection Diseases (tuberculosis, CMV, mononucleosis, HIV, etc.)
Exposure to abuse/ Family Violence
Bone/Joint Conditions
Overweight/Obesity
Underweight/Eating Concerns
Other Health Problems
Is your child currently taking any daily medication?
Yes
No
If yes, please list name of medication, dose and purpose for each:
Does your child have any allergies to medications or foods?
Yes
No
If yes, please list:
Has your child been seen in the ER in the last year?
Yes
No
If yes, for what?
Has your child had any surgeries or hospitalizations?
Yes
No
If yes, what for and when?
Does your child see any specialists?
Yes
No
If yes, what for & Who do they see?
Has your child ever received psychological counseling?
Yes
No
If so, by whom (professional/agency) and when:
Do you have any concerns that you were hoping to address at your child's first visit?
Yes
No
If yes please explain:
Is there any sensitive information pertaining to custody or family dynamic that you request not be discussed in front of your child?
No
Specify:
How did you hear about us?
Social Media
OBGYN
Friend/Family Member
Web Search
Other
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