PEDIATRIC - Patient Questionnaire
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- Martin Chambers
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1 Chart # PEDIATRIC - Patient Questionnaire Completed by Relation Please check y yes or n no, circle or explain where required. N/A-Not Applicable NAME: DATE OF BIRTH DATE: Previous medical care - DR. Dental Care Eye Exam n PREGNANCY & BIRTH Mother s age at pregnancy? Any illness during pregnancy? Medications during pregnancy? (exclude vitamins & iron) Smoking - alcohol - street drugs - during pregnancy? Was baby early - late - on time? Type of delivery? Birth weight Length Complications? Apgar Problems with baby at birth? Breathing Jaundice Other Problem soon after? Nursery or home? PAST MEDICAL HISTORY Allergic reactions? Medicine Food Animals Insect bites Medications taken on a regular basis? (exclude vitamins) Immunizations - up to date Do you have a record? Hospitalizations - (when-where-why?) Serious injuries (when-where?) Red Measles Mumps German (3 day) Measles Chicken Pox Whooping Cough Rheumatic Fever Scarlet Fever Recurrent infect(s)? (3 or more) Ear Throat Asthma/ Eczema/ Wheezing Hives Seizures Bleeding tendency Anemia Hepatitis Problems with-hearing Vision Blood Transfusions Other- FEEDING & NUTRITION Food Allergies Appetite usually good? Colic or feeding problems during first 3 months? Breast fed? Number of months? Formula? Current Brand? Vitamins? Brand? Fluoride? Special diet? FAMILY PROFILE Parents - Married? Separated? Divorced? Father s Age? Highest school grade? Health? Mother s Age Highest school grade? Health? (List child s brothers & sisters & their ages) FAMILY MEDICAL HISTORY List all blood relatives of your child who have had the following problem - Use abbrev. (F) Father, (M) Mother, (B) Brother, (S) Sister, (MM) Mother s Mother, (MF) Mother s Father, (FM) Father s Mother, (FF) Father s Father (A) Aunt, (U) Uncle, (C) Cousin Anemia / Blood Disorder Asthma Mental Retardation Drug Proglem Alcoholism Cancer Aids Cystic Fibrosis Musc. Dystrophy Tuberculosis Arthritis DEVELOPMENT & BEHAVIOR Age at which child - Sat alone Walked Used sentences Toilet trained Bicycled Development compared to other children? Grade in school Problems in school? Learning problems? Getting along with other children? Behavior problems? Bad habits? Bedwetting? Nail biting? Sleeping? Hobbies - sports - social activities? Use of street or illegal drugs? SYNOPSIS Epilepsy / Seizures Heart Disease High Blood Pressure Cholesterol Problem Migraine Sudden Infant Death Birth Defects Early Deafness Diabetes
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4 Tampa Family Health Centers P.O. Box Tampa, Florida Financial Policy Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy which we require that you read and sign prior to any treatment. All patients must complete our information and Insurance Form before seeing the doctor. FULL PAYMENT IS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, PERSONAL CHECKS, STRAIGHT MEDICAID, MEDICARE, PRIVATE INSURANCE, HILLSBOROUGH COUNTY HEALTH CARE, PCA CENTURY, STAY WELL, PHYSICIANS HEALTHCARE, TGH HEALTH EASE. WE OFFER A SLIDING SCALE PAYMENT PLAN BASED ON CURRENT WEEKLY OR BIWEEKLY INCOME. PAYMENT ARRANGEMENTS BASED ON ABILITY TO PAY CAN BE MADE THROUGH OUR FINANCIAL COUNSELOR. Regarding Insurance We may accept assignment of insurance benefits after your second visit. However, we do require 50% of the bill to be paid at the time of service. The balance is your responsibility whether or not your insurance company pays. We cannot bill your insurance company unless you give us your insurance information and an original claim form. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 45 days, the balance will automatically be transferred to you, the patient, for the full amount of the office visit. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare program and/or other medical insurance. All co-pays and deductibles are due prior to treatment.
5 USUAL AND CUSTOMARY RATES Our practice is committed to providing the best treatment for all patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates. Adult Patients Adult patients are responsible for full payment at the time of service. Minor Patients The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment. For unaccompanied minors, a signed, notarized letter from the parent or legal guardian is required at the time of service for all treatment. Non-emergency treatment will be denied unless charges have been pre-authorized and payment arrangements have been pre-approved. A payment will be due at the time of service. Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns. I have read the Financial Policy. I understand and agree to this Financial Policy. X Date Signature of Patient X Date Signature of Responsible Party
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7 Tampa Family Health Centers, Inc. Medical Treatment Consent Form PATIENT NAME: (Please print full name) Consent for Treatment: Knowing that I (or the patient indicated on the top of this form) desire evaluation and/or treatment at Tampa Family Health Centers, Inc., I voluntarily consent to such care. I consent to routine diagnostic procedures, including but not limited to x-rays, blood draw, laboratory tests, administration of medication and to medical treatment by physicians, and other medical staff members of Tampa Family Health Centers, Inc. and other health care providers who may be called upon to consult or assist in my care as judged necessary by my treating physician or medical staff. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the results of my examination or treatment at Tampa Family Health Centers, Inc. I acknowledge the treatment at Tampa Family Health Centers, Inc. is intended to address specific episodic illnesses or injury and is not intended to substitute for comprehensive care in lieu of a primary care physician or other specialized physician. In order to provide the best chance for successful treatment I accept responsibility to follow the advice of my treating health care provider including compliance with medications, summary instructions and re-evaluation with follow up or referral physicians. I agree to return to the clinic or seek care in an Emergency Department of a hospital if my condition substantially changes. I further agree to hold harmless the physicians and staff of Tampa Family Health Centers, Inc. should I fail to comply with the above conditions. Patients at Tampa Family Health Centers, Inc. will be treated regardless of race, color, national origin, disability or religion. Notwithstanding the above criteria, Tampa Family Health Centers, Inc. reserves the right to refuse care to any individual who may have an unpaid balance, exhibits rude or disruptive behavior or any reason at the discretion of the provider staff on duty. This consent shall remain in force until such time as it is specifically revoked. Signature of patient or patient representative: Date:
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