Developmental Pediatrics of Central Jersey

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1 PATIENT INFORMATION: CLIENT INFORMATION Date: SS# Name: (Last) (First) (M.I.) Birthdate: Sex: Race: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Which telephone number is preferred: ( ) Home ( ) Work ( ) Cell Address: Regarding the office staff or physician leaving information or confirming appointments on my answering machine, voic or with my answering service: Yes, I give permission for medical information to be left. No, I do not want messages or medical information left. MEDICAL INFORMATION: Primary Care Physician: Address: City: State: Zip: Phone: PARENT(S)/LEGAL GUARDIAN(S): 1. Name: (Last) (First) (M.I) Address: City: State: Zip: Relationship: Phone: 1. Name: (Last) (First) (M.I) Address: City: State: Zip: Relationship: Phone: EMERGENCY CONTACT INFORMATION:(if we are unable to reach you): Name: (Last) (First) (M.I) Relationship: Phone: 1

2 Additionally, the following person(s) have permission to transport the patient and to provide information in my absence: Name: Relationship: Name: Relationship: Name: Relationship: ADOPTION: If your child was adopted, please circle the appropriate response: 1. The adoption can be discussed freely in front of the child ( ) Yes ( ) N0 2. Please only discuss the adoption when the child is NOT present If you answered YES to question 2, please answer the following: 1. How old was your child at the time of adoption? 2. What country was your child adopted from? 3. Do you have any birh records or information about the birth family? 4. Did you have an open adoption? 5. If yes, are you still in contact with the birth parents? REFERRAL: Were you referred to Developmental Pediatrics of Central Jersey? If so, by whom: Name: Organization: Address: Therapist Friend Physician 2

3 QUESTIONNAIRE Please help us understand your child better by completing the following form. I. IDENTIFYING INFORMATION Patient s Name Birthdate / / Sex Diagnosis / Reason for Visit Current School Placement Name of School Address Classification Last CST Evaluation Current Therapies Received in School: Physical Therapy Frequency Occupational Therapy Frequency Speech Therapy Frequency Psychiatry Frequency Current Physicians and Addresses Pediatrician Neurologist Orthopedist Other How were you referred to Developmental Pediatrics of Central Jersey? Has your child been registered with NJ Special Health Services? If yes, when? Case Manager Current Medications Name Dose Date Started Allergies Medications Food / Other 3

4 II. FAMILY INFORMATION Mother Birthdate Faher Birthdate Siblings and other household members: Name Relationship Age Problem / Diagnosis Has anyone in the family (mother or father s side) had significant medical or emotional illness? If yes, please clarify III. MATERNAL PREGNANCY HISTORY Number of Pregnancies Miscarriages Abortions Full Term Premature Health during pregnancy Ilness Accidents Medication / Vitamins taken Drugs / Alcohol / Smoking Any other difficulties Labor and Delivery Hospital Length of Labor Medications given (if any) Complications during labor (if any) Delivery ( ) Normal ( ) Induced ( ) C- section Complications during delivery (if any) Birthweight Length APGAR Neonatal Care ( ) Regular Nursery ( ) Intensive Care Nursery How old was the baby when he / she came home? Jaundice: ( ) Yes ( ) N Did the baby have any of the following after delivery: Turn blue Have difficulty breathing 4

5 Need a respirator How long? Have a seizure Have bleeding in the brain Have surgery Medications What type? Details on any of the above IV. MEDICAL / DEVELOPMENTAL HISTORY Previous medical / therapy evaluations (Please list type of evaluation, facility, and clinician or physician) Previous therapy / treatment (Please list type of evaluation, facility, and clinician or physician) Operations / hospitalizations (Please list dates, facility, and type of operation) Serious illnesses / injuries / loss of consciousness (Please list dates and types) V. DEVELOPMENTAL MILESTONES Please indicate at what age your child accomplished each of the following or if you do not remember the age please check ( ) if your child had difficulty achieving Motor Skills Held head up Sat up without support Crawled on the floor Stood alone Transferred from hand to hand Held bottle Built blocks Age / Difficulty Speech and Feeding Smiled Babbled Played games: ( )peek- a- boo, ( ) patti- cake, ( ) other Words / Phrases Simple sentences Baby Food Table food Age / Difficulty 5

6 Motor Skills Age / Speech and Feeding Difficulty Used ( ) spoon, ( ) fork, ( ) cup Drank from cup Did ( )buttons, ( ) tied shoes Pointed to body parts Toilet trained Dry at night Recognized colors Recognized shapes Recognized numbers Recognized letters VI. PRESENT DEVELOPMENT Age / Difficulty Medical problems: (ear infections, seizures, allergies, etc) Vision: ( ) Good ( ) Poor Formally tested? Glasses Hearing: ( ) Good ( ) Poor Formally tested? If yes, when? Teeth: ( ) Good ( ) Fair ( ) Poor Seen by Dentist? If yes, when? Feeding difficulties: Sleeping difficulties : Toilet difficulties: Walking patern: ( ) Normal ( ) Abnormal Coordination: ( ) Good ( ) Fair ( ) Poor Describe details of any of the above Wears splints / braces: If yes, what kind? Special equipment: ( ) wheelchair ( ) walker ( ) stander ( ) bath chair ( ) other Talking Pattern (examples of speech): BEHAVIOR / PERSONALITY: Please check all that apply Activity Level: ( ) Quiet ( ) Average ( ) Overactive ( ) Hyperactive ( ) Cooperative ( ) Self Confident ( ) Pays attention ( ) Follows directions ( ) Understands what is said ( ) Generally happy ( ) Frustrates easily ( ) Other How does your child interact with: Peers Siblings Mother Father Other Adults 6

7 Favorite activities: Dislikes: Fears: How do you discipline your child? What areas of behavior are harder for you to deal with? Does your child have difficulty separating from you? What else would like us to know about your child? Signature of Patient or Guardian Print Name of Patient or Guardian Date Relationship to Patient 7

8 PATIENT BILL OF RIGHTS Welcome to our office. Please be advised that we are legally obligated to provide you with this list of your rights. Please read the following carefully and feel free to ask questions if there is something you do not fully understand. After you have read this list of rights, please acknowledge that we have provided you with this important information by signing below. IT IS OUR LEGAL DUTY and OBLIGATION TO To treat you with consideration and respect in a safe setting free from all forms of abuse and harassment. Your privacy will be protected. To keep all communications and records about your care confidential. In general, you have the right to see all the information in your health records. To provide clearly written and spoken information in words you can understand. To provide all the information you need to make an informed decision about your care including information about your options, risks and benefits, possible outcomes, possible side effects, who is providing your care and all possible costs. To respect your decision to refuse care. To allow you to leave the office even if the physician advises against it. To provide you with the freedom of restraints and seclusion of any form that is not medically necessary. To provide you with all available information about possible research participation and obtain your informed consent. To give you the opportunity to examine and receive an explanation of your bill regardless of source of payment. To allow you to express a concern or complaint and receive a prompt response. You also have the right to file a formal grievance if you are not satisfied with the resolution of your complaint. I have read and fully understand this Patient Bill of Rights. Signature of Patient or Legal Guardian Date 8

9 CONSENT FOR TREATMENT Developmental Pediatrics of Central Jersey is authorized to initiate Evaluative / Diagnostic / Therapeutic procedures on the above named patient to clarify issues pertinent to the health, development, or adjustment of the patient. Signature of Patient of Legal Guardian Date FINANCIAL POLICY I understand that Developmental Pediatrics of Central Jersey is a fee- for- service practice and does not have contracts with any insurance companies therefore does not accept insurance payment. All payments are made by cash, check, or credit card for the full amount at the time of service. Developmental Pediatrics of Central Jersey will provide an itemized statement for you to submit to your insurance company for out- of- network reimbursement, should you choose to do so. I understand that my insurance company may not provide out- of- network benefits and I will contact my insurance company prior to my appointment. I have read and understand the above stated policy. Signature of Patient or Guardian Date CANCELLATION POLICY I understand that when I schedule an appointment at Developmental Pediatrics of Central Jersey this time is reserved for my child only. Appointment times may be blocked off for up to 2 hours. Developmental Pediatrics of Central Jersey makes reminder calls and confirmations one week prior to your appointment. Please check your mobile and/or home phone messages as well as your s. I understand that I need to notify the office at least 24 hours in advance if I need to cancel my appointment for any reason. Developmental Pediatrics of Central Jersey understands that illness is unpredictable. Our no- show policy is to charge for the entire fee for an appointment missed without prior notification. If I cancel an appointment without appropriate notification (<24 hours), I will be billed 50% for that appointment. I have read and understand the above stated policy. Signature of Patient or Guardian Date 9

10 AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION Today s Date: Patient Name: Date of Birth: Parent / Legal Guardian: The following individual or organization is authorized to make the disclosure of the above named individual s health information as disclosed below. Developmental Pediatrics of Central Jersey Name of Individual/Organization: Relationship to Patient (if applicable): Address: City: State: Zip: Phone: Fax: The type of information to be disclosed: All Medical Information (Lab Results, X- Ray and/or other Diagnostic tests, Medications, Immunizations, etc) Consultation Reports (medical, psychological and/or speech- language evaluation) Dates of Service: From / / To / / I understand that this information may include information relating to AIDs or HIV, treatment of drug or alcohol abuse, or mental / behavioral health / psychiatric care. This information may be disclosed to and used by the following individual or organization: Developmental Pediatrics of Central Jersey Name of Individual/Organization: Relationship to Patient (if applicable): Address: City: State: Zip: Phone: Fax: Name of Individual/Organization: Relationship to Patient (if applicable): Address: City: State: Zip: Phone: Fax: I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. If I fail to specify an expiration date, event or condition, this authorization will expire in sixty (60) days. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rule. 10

11 AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION (continued) I authorize the use or disclosure of the above named individual s health information as discussed above. Signature of Patient/Legal Guardian Print Name of Patient or Legal Guardian Date: 11

12 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT (please refer to the attached Notice of Privacy Practices) I understand that, under the Health and Insurance Portability and Accountability Act (HIPPA), I have certain rights to privacy regarding my protected health information. I acknowledge that I have received and read the Notice of Privacy Practices. I understand that Developmental Pediatrics of Central Jersey has the right to change the Notice of Privacy Practices from time to time that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. Signature of Patient or Legal Guardian Date Print Name of Patient or Legal Guardian 12

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