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KC CHILDREN'S SURGICAL CENTER MEDICAL QUESTIONNAIRE
NAME
First Name
Last Name
BIRTHDATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
HEIGHT
WEIGHT
BMI
TODAY'S DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PRIMARY CARE DOCTOR
*
PHONE
Format: (000) 000-0000.
LAST DOCTOR APPOINTMENT: DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
LAST DOCTOR APPOINTMENT: WHO
First Name
Last Name
MEDICAL QUESTIONNAIRE
Rows
YES
NO
HAVE YOU / PATIENT EVER HAD A PROCEDURE THAT REQUIRED ANESTHESIA?
DO YOU / PATIENT HAVE ANY ALLERGIES TO FOOD/MEDICATIONS?
HAS PATIENT EVER BEEN HOSPITALIZED?
ARE YOU / PATIENT SEEING ANY SPECIALISTS?
WERE YOU / PATIENT BORN PREMATURE?
ANY HEART PROBLEMS SUCH AS MURMURS, FROM BIRTH UNTIL NOW?
ANY BREATHING PROBLEMS SUCH AS ASTHMA, BRONCHITIS OR WHEEZING?
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Rows
YES
NO
DO YOU / PATIENT SNORE WHEN SLEEPING?
HAVE YOU / PATIENT BEEN DIAGNOSED WITH SLEEP APNEA?
ANY NEUROLOGICAL ISSUES LIKE SEIZURES, STROKES OR MUSCLE WEAKNESS?
ANY PROBLEMS WITH THE LIVER, KIDNEYS OR DIABETES? (insulin dependent)
ANY ABNORMALITIES, INJURIES TO NECK OR FACE OR NEED FOR A WHEELCHAIR?
ANY SPECIAL HEALTHCARE NEEDS? (genetic syndrome, autism or mental disabilities)
ARE YOU / PATIENT TAKING ANY MEDICATIONS, INCLUDING HERBAL REMEDIES?
HAVE YOU / PATIENT BEEN SICK IN THE LAST MONTH WITH FEVER, VOMITING, DIARRHEA OR COLD-LIKE SYMPTOMS?
ANY CONTAGIOUS DISEASES OR SKIN INFECTIONS, SUCH AS HEAD LICE?
DO YOU / PATIENT HAVE A HISTORY OF BED WETTING OR INCONTINENCE?
HAVE YOU / ANYONE YOU HAVE BEEN IN CONTACT WITH TRAVELED OUTSIDE THE UNITED STATES WITHIN THE PAST 30 DAYS?
ANY OTHER MEDICAL CONDITIONS WE NEED TO BE AWARE OF?
ARE YOUR CHILD'S IMMUNIZATIONS CURRENT?
HAS YOUR CHILD BEEN IMMUNIZED IN THE LAST WEEK?
IS YOUR CHILD CURRENTLY RECEIVING HORMONE THERAPY?
HAS YOUR CHILD BEEN DIAGNOSED WITH A BLEEDING DISORDER OR ANEMIA?
HAS YOUR CHILD EVER RECEIVED A BLOOD TRANSFUSION?
HAS YOUR CHILD EVER HAD A TUMOR OR CANCER OF ANY KIND?
HAS YOUR CHILD EVER RECEIVED CHEMOTHERAPY OR RADIATION?
Please list: (Other medical conditions)
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To the best of my knowledge, the information on this form is complete.
Signature
Relationship to Patient
Print Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
This Medical Questionnaire has been reviewed:
NO MEDICAL CLEARANCE REQUIRED
PATIENT WILL NEED MEDICAL CLEARANCE TO PROCEED
Nurse Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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PATIENT INFORMATION
Please send at least 2 weeks from scheduled OR date
Date of Surgery:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Office:
Patient Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
SEX:
Male
Female
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
Alternate Number:
Format: (000) 000-0000.
Mother's Name:
First Name
Last Name
Father's Name:
First Name
Last Name
Medical Insurance Information
Please attach a copy of the front and back of the insurance card
Insurance Company:
Insurance Phone Number:
Format: (000) 000-0000.
Policy Holder Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security Number:
Subscriber ID:
Group Number:
PLEASE UPLOAD A COPY OF THE FRONT AND BACK OF THE INSURANCE CARD
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MEDICAID INSURANCE
Patient Name:
First Name
Last Name
Medicaid Number:
Medicaid Plan:
Notes:
We will need the dental approval letter for anesthesia for all patients 6 years or younger with Medicaid insurance. Also Please provide clinicals notes, x-rays and patient's Criteria for Dental Therapy Under General Anesthesia form.
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