PEDIATRIC MEDICAL HISTORY FORM
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1 Patient s First and Last Name / / PEDIATRIC MEDICAL HISTORY FORM PRESENT HEALTH CONCERN (Reason for today s visit.) ALLERGIES List all allergies to medications, foods and/or other agents. Medication/Food/Other Side Effect or Allergic Reaction MEDICATIONS List all prescription medications, nonprescription medications and vitamins. Medication/Other Dose How Many Times Per Day CHILD S HEALTH HISTORY Mark the following medical issues or conditions that the child has experienced. o Fainting Spells o Seizures o Feet/Leg Issues o Broken Bones o Growing Pains o Muscle Pain o Poor Posture o Scoliosis o Weight Issues o Headaches o Dizziness o Mental Health Issues o ADHD o Anxiety o Depression o Suicide Attempt o Fatigue o Weakness o Issues with Urination o Blood in Urine o Kidney Stones o Constipation o Diarrhea o Blood in Stool o Abdominal Pain o Appetite Issues o Digestion Issues o Colic o Reflux o Nutrition Issues o Wheezing/Cough o Shortness of Breath o Asthma o Allergies o Repeated Infections/Colds o Chronic Ear Infections o Thyroid Problems o Diabetes o Increased Thirst o Pain in Joints o Back Pain o Chest Pain o Palpitations o Bleeding/Clotting Issues o Anemia o Blood Transfusion o High Cholesterol o Vision Problems o Hearing Problems o Problems with Teeth o Sinus Problems o Skin Issues o Fever o Nausea or Vomiting o Cancer, Type/Age o Other BIRTH HISTORY Birth Weight Length APGAR Score Was Baby Born Preterm o Yes o No If Yes, Weeks Gestation Method of Delivery o Vaginal o Caesarean Section How Long Did Baby Stay in Hospital After Birth During Pregnancy Did the Mother: Have Medical Problems o Yes o No Smoke o Yes o No Use Medications o Yes o No Use Alcohol o Yes o No Use Any Drugs o Yes o No Have Complications in Labor/Delivery o Yes o No SURGICAL, HOSPITALIZATION AND MEDICAL ILLNESS HISTORY Surgery, Hospitalization, and/or Medical Illness Date
2 Patient s First and Last Name / / FAMILY HISTORY Mark the following medical issues or conditions that any of your family members have experienced. Specify if it is mom, dad, brother, sister, or other blood relative. o Cancer, Type/Age o High Cholesterol o High Blood Pressure o Heart Disease o Bleeding/Clotting Issues o Seizures o Mental/Emotional Issues o Depression o Anxiety o Alcoholism o Drug Addiction o Thyroid Abnormalities o Diabetes o Type 1 o Type 2 o Arthritis o Asthma o Allergies o Sickle Cell o Other DEVELOPMENTAL HISTORY Do you have any concerns about the following: Physical Development o Yes o No Mental Development o Yes o No Emotional Development o Yes o No Behavior Problems o Yes o No Eating Habits o Yes o No Sleeping Habits o Yes o No School Experience o Yes o No Bathroom/Toilet Habits o Yes o No Difficulty Concentrating o Yes o No Sitting/Standing/Crawling/Walking Issues o Yes o No Menstruation Issues o Yes o No Issues in Social Settings o Yes o No Other Are There Smokers in the Home o Yes o No Does Child Regularly Eat Nutritious Meals o Yes o No Exercise Regularly o Yes o No Does Child Often Seem Overwhelmed/Stressed/Sad o Yes o No Have there been any recent major changes or stresses in child s life o Yes o No If Yes, Explain IMMUNIZATIONS Circle the immunizations the child has received and list the date they were administered. MMR Pneumococcal HIB Influenza Tetanus DPT HPV Polio Hepatitis A Hepatitis B Chicken Pox Other Vaccinations o Up To Date o Behind o Chose to Decline Vaccinations List Adverse Reactions to Vaccinations I hereby certify that the above information is true and correct to the best of my knowledge. Patient/Representative Name (Print) Relationship to Patient Signature Date / / 1/7/14
3 PATIENT INFORMATION FORM PATIENT DEMOGRAPHICS Last Name:_ First: Middle: Date of Birth: / / Social Security #: - - Sex: Male Female Marital Status: Single Married Partnered Divorced Widowed Separated Other Home Address: City: State: Zip Code: 2nd Seasonal Address: City: State Zip Code: Home Phone: Cell Phone: Occupation: Status: Full Time Part Time Retired Student Other Employer: Work Phone: Employer Address: Preferred Pharmacy: Phone #: How did you hear about our practice: RESPONSIBLE PARTY RELATION TO PATIENT Self Spouse Parent Legal Guardian Other Last Name:_ First: Middle: Date of Birth: / / Social Security #: - - Home Address: City: State: Zip Code: Home Phone: Cell Phone: Occupation: Status: Full Time Part Time Retired Student Other Employer: Work Phone: Employer Address: EMERGENCY INFORMATION In case of emergency notify: Relation: Home Address: City: State: Zip Code: Home Phone: Cell Phone: INSURANCE INFORMATION Please provide your current insurance card. PRIMARY INSURANCE SECONDARY INSURANCE Insurance Name: Policy ID #: Group/Account#: Cardholders Name: DOB: SSN: Relation to Patient: Insurance Name: Policy ID #: Group/Account#: Cardholders Name: DOB: SSN: Relation to Patient: I hereby certify the above information is true and correct to the best of my knowledge. I understand that while Desert Wells Family Medicine contracts with many insurance companies, it is my responsibility to verify with my plan that Desert Wells Family Medicine is a participating provider. It is also my responsibility to find out what my coverage options and benefits are with my insurance plan. I hereby authorize Desert Wells Family Medicine to submit insurance claim forms along with medical records necessary to obtain payment from my insurance company. I understand that I am responsible for all charges regardless of insurance coverage. I acknowledge that photo IDs taken are used to assist in patient recognition per HIPAA guidelines. SIGNED: DATE: WITNESS SIGNATURE: DATE: 1/7/14
4 SICK VISITS VS. WELL VISITS OR BOTH? SICK VISIT This is an office visit for an acute problem or flare-up of a chronic problem. This could also be an office visit to follow-up on chronic problems (Diabetes, Cholesterol, Blood Pressure, etc.). WELL VISIT This is an office visit for a routine physical exam or yearly health maintenance exam. SICK/WELL VISIT This is a combination visit of a routine physical exam where an acute or chronic issue is addressed as well. For example, if you presented today for a well visit and you have an acute or chronic issue you would like addressed, it is considered a combination visit and must be billed differently than just a well visit or just a sick visit. WHY IT IS BILLED DIFFERENTLY It is billed differently to account for the additional work, expertise and time required for a combination visit (additional lab work, x-ray, referrals and/or prescription medications). It involves additional documentation as well. For example, think about taking your vehicle in for an oil change (routine maintenance), and mentioning to the mechanic that your brakes are squeaking and your windshield wipers are not working well. In addition to the oil change, you might require additional brake work if a problem was found, and replacement windshield wipers. Since additional services were provided, you would be charged more than just for the oil change. HOW THIS AFFECTS ME Although many insurance companies acknowledge the sick/well visit combination, some of them still require the patient to pay two co-pays or have additional costs applied to his/her annual deductible. ANNUAL PHYSICAL EXAMS Annual physical exams target preventative care and are billed as such. Medication refills and/or other ailments, injuries, or illnesses addressed during an annual physical exam are billed IN ADDITION to the annual physical. These charges may be passed on to the patient. Please check with your insurance company to confirm your coverage for all types of doctor visits. We realize this can be confusing, and if you have any questions or concerns after reviewing this material, please ask. Print Patient s Name Patient s Signature Today s Date 1/7/14
5 PAYMENT POLICY Thank you for choosing us as your primary care provider. We are committed to providing you with quality health care. Please read this payment policy, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request. INSURANCE Desert Wells Family Medicine contracts with many insurance companies. It is the patient s responsibility to verify with their plan that Desert Wells Family Medicine is a participating provider. It is also the patient s responsibility to find out what coverage options and benefits are with your insurance plan. Desert Wells Family Medicine will submit insurance claim forms along with the medical records necessary to obtain payment from your insurance company. The patient is responsible for all charges regardless of insurance coverage. If you are not insured by a plan we are contracted with, payment in full is due at each visit. If you are insured by a plan we are contracted with, but don t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Please contact your insurance company with any questions you may have regarding your coverage. CO-PAYMENTS AND DEDUCTIBLES All co-payments must be paid at the time of service. Deductibles must be paid upon receipt of the invoice. A $40 fee will be charged in the event of a returned check. NON-COVERED SERVICES Please be aware that any services considered to be a non-covered benefit by your insurance will be your financial responsibility. PROOF OF INSURANCE We must obtain a copy of your current insurance card. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. CLAIMS SUBMISSION We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly to them. It is your responsibility to comply with their request. NONPAYMENT Please be aware that if a balance remains unpaid, we may refer your account to a collection agency, and you and your immediate family members may be discharged from the practice. MISSED AND LATE APPOINTMENT POLICY Our office has a 24 business hour cancellation policy, otherwise there will be a $30 fee billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment. I have read and understand the payment policy and agree to abide by its guidelines. Patient s Name (Print) Patient s Signature Today s Date CONSENT FOR PHONE CONTACT Desert Wells Family Medicine MAY leave a voice mail message for me on my: o Yes Home Phone: o Yes Cell Phone: o Yes Work Phone: o Yes Other (specify): o Never leave any medical information on any voice mail message for me, simply ask me to call back. Please note, this does not apply to messages regarding unpaid bills. Patient s Signature (Parent or Legal Guardian If a Minor) Desert Wells Family Medicine MAY discuss medical information regarding me with: o Yes My husband/wife/partner (Name/Relationship): o Yes Power of Attorney (Name/Relationship): o Yes Other (Name/Relationship): Date 1/03/2014
6 20715 E. Ocotillo Road, Suite 102 Queen Creek, AZ Tel: Fax: NOTICE OF PRIVACY POLICY FOR PROTECTED HEALTH INFORMATION (PHI) This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. How we may use and disclose medical information about you: TREATMENT We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other practice personnel who are involved in your medical care and treatment. PAYMENT We may use and disclose medical information about you so that the treatment and services which we provide to you at our practice may be billed to you, and payment may be collected from you and/or your insurance company or other responsible third party. HEALTH CARE OPERATION We may use and disclose medical information about you for our practice operations. These uses and disclosures are necessary to operate our practice and make sure that all of our patients receive quality care. EMERGENCIES We may use or disclose your medical information in an emergency treatment situation. WORKERS COMPENSATION We may release medical information about you to comply with worker s compensation laws or similar programs. WHO HAS ACCESS TO THIS INFORMATION Any person or persons you designate in writing, people directly involved in your medical care, and/or people creating and maintaining your medical record. YOUR RIGHTS You have the right to inspect your Protected Health Information. You also have the right to amend any errors you may find in your records. COMPLAINTS If you have any complaints concerning our privacy practices, you may contact the Secretary of the Department of Health and Human Services. All complaints must be made in writing. To file a complaint with the practice contact the office manager at (480) This practice reserves the right to amend our privacy policy as dictated by law, without sending you a copy of the amendment. Any changes to this policy will be posted in our office. This notice is effective as of January 31, I understand I will be provided a copy of the Privacy Policy upon request. Print Patient Name Patient Signature of Person Authorizing Consent Date 1/7/2014
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