Consent by Proxy for Non Urgent Pediatric Care

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1 Consent by Proxy for on Urgent Pediatric Care Patient ame: DOB: Patient ame: DOB: Patient ame: DOB: Patient ame: DOB: I (we) appoint as our proxy decision maker: ame: Relationship to patient: ame: Relationship to patient: ame: Relationship to patient: The person named above has my permission to consent to non-urgent medical care for my (our) children listed on this document. I (we) have the legal right to delegate consent to the proxy decision maker, who is an adult and legally and medically competent to exercise the authority delegated. Be advised that protected patient healthcare information may be shared with the proxy to facilitate informed consent. Limitations Identify any limitations for medical services which this consent by proxy is given. If none, state none. Contact Information If the nature of the medical care is not routine, please contact me (us) regarding the health care of my (our) children at the following telephone number(s). If you are unable to contact me (us), you may rely on the proxy decision maker for consent. Parents ame: Daytime Phone: Evening Phone: Cell Phone: Parent or Legal Guardian Signature Parents ame: Daytime Phone: Evening Phone: Cell Phone: Parent or Legal Guardian Signature Rev. 10/13/10

2 MPPA Health History Patient ame: of Birth: Gender: Female Male : A. Child s Birth History 2. Illnesses Illnesses during pregnancy? Has your child ever had the following? Medications taken during pregnancy? Group B strep positive? Antibiotics during delivery? Where was your baby born? Referring OB/Doctor? Baby s gestational age: Delivery: Vaginal C-Section - Reason for C-Section Age at discharge from hospital: Complications during hospitalization: Was your baby: Jaundiced: Breast fed: Formula fed: Pass the hearing screen? Which formula? Did your baby receive: Vitamin K shot? Hepatitis B vaccine in the hospital? Erythromycin eye ointment? If yes, date vaccine received: weeks If yes, number of doses: B. Child s Past Medical History 1. Hospitalizations/Major Illnesses or Major Injuries/Surgeries ear Major Illness/Injury/Surgery Hospital if required days Birth Weight: lbs oz Birth Length: inches Abdominal pain.. ADHD Allergic rhinitis. Allergies Anemia..... Asthma / wheezing. Autism Bleeding disorder... Blood transfusions..... Chickenpox. Congenital deformity..... Congenital heart disease... Constipation.... Cystic fibrosis.. Developmental delay. Diabetes mellitus... Eczema... Epilepsy... Failure to thrive.. Febrile seizures.. Headache... Hearing problems Heart murmur..... Hepatitis Hyperthyroidism. Hypothyroidism Jaundice - history of Learning problem... Migraine... Pneumonia.. Prematurity - history of... Recurrent ear infections.... Seizures / epilepsy..... Speech delay Vision problems..... Whooping cough. C. Developmental History Does your child have allergic reactions to: Medicines Foods: Other: Describe: Does your child take any daily or seasonal medications? Describe: Milestones Rolled Over Sat alone Crawled Age Achieved Milestones Walked Spoke first words Used sentences Age Achieved Are your child s vaccinations up to date? Stood alone Toilet trained over»

3 Health History Continued D. Family History E. Social History Father Mother Relation Age Health Condition Are there any cigarette smokers in the home? Are there any pets in the home? Please list:: Brothers How many people live in the home? Please list:: 7 8 Sisters Does your child attend daycare? Describe: Preschool? School? Grade Level: Have any of your child s blood relatives had any of the following conditions? Medical Condition Relation to child F. Additional Information AIDS Arthritis, gout Asthma Birth defects Bleeding disorders Cancer Cystic fibrosis Diabetes Epilepsy / seizures Heart Disease Hepatitis Hypertension Kidney Disease Mental Illness Muscular dystrophy Obesity Tuberculosis Other Signature: Relation to patient: Reviewed by / date: Rev. 10/2012

4 MPPA REVIEW OF SSTEMS Patient ame: of birth: Please review the following list and check those that your child has complained about or suffered from in the past year. Mark if your child has experienced a problem, if not. Depending on the age of your child some of these questions may not apply. If so, please mark A. Chills Fever Persistently Tired Sweats Loss of Weight Acne Eczema GEERAL SKI Slow healing bruises Changing mole Excessive sweating Hives Persistent rashes HEAD,EE,EAR,OSE,THROAT Vision problems Excessive tearing Loss of hearing Ear discharge Frequent ear infections Earache Frequent nosebleeds asal congestion Mouth breathing Snoring Allergies Sinus problems Bleeding gums Hoarseness Sores in mouth/gums Dental problems Been to dentist Frequent tonsil infections Difficulty talking Stuttering RESPIRATOR ight-time cough Recurrent/chronic cough Shortness of breath Unable to keep up with peers Difficulty breathing Wheezing Chest pain CARDIOVASCULAR Heart murmur Irregular heart beat Hypertension Difficulty breathing lying down GASTROITESTIAL Food restriction/dieting Stomach aches Dark stools Bloody stools Constipation Diarrhea ausea Vomiting GEITOURIAR Unusual urine odor Blood in urine Reviewed by / Discharge from vagina or penis Frequent urination Painful urination Bed-wetting problems MUSCULOSKELETAL Prior fracture Scoliosis Back Pain Painful joints Swollen joints ERVOUS SSTEM Fainting Speech / spells gait problems Dizzy Fainting spells Headaches Seizures Tremors Weakness PSCHIATRIC Anxiety Change in sleep pattern Depression Inability to concentrate EDOCRIE Excessive Appetite change thirst Cold intolerance Excessive thirst Excessive urination Heat intolerance Easy bruising ose bleeds Form Revised 5/25/05 HEMATOLOGIC Abnormal bleeding

5 Mesa Pediatrics Vaccine Refusal Policy Mesa Pediatrics remains committed to the continuing pursuit of excellence in pediatric medicine, which includes preventive care. Our providers strongly believe in the use of childhood vaccinations to prevent serious medical diseases and in some cases, even death. We also believe in the safety of all of our patients, which at times includes young infants who are not yet eligible to receive these important vaccines. For these reasons, starting June 1 st, 2015, Mesa Pediatrics will no longer be accepting new patients who choose to refuse all vaccinations for their children. If you have questions regarding this policy, please do not hesitate to ask your provider. I have read and understand Mesa Pediatrics Vaccine Refusal Policy. I am the parent of said minor child, or the court appointed guardian for the patient, and am authorized to act on the patient s behalf. Patient ame: of Birth: (Signature of parent or guardian) ()

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