Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at

Transcription

1 Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child better, we require that all information in this packet must be completed and returned to us prior to making an appointment. Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at Phone Fax Thank you.

2 Patient: Patient's Legal Name (Last, First, Middle) New Patient Intake Form Date of Birth: Age Sex Race Religion Home Address City State Zip Code Preferred Phone Number Father/Guardian Father's Name Date of Birth: Address (if different than above) City State Zip Code Home Number Cell Number Work Number Mother/Guardian Mother's Name Date of Birth: Address (if different than above) City State Zip Code Home Number Cell Number Work Number Emergency Contacts (other than listed above) Name Phone Number Relationship to Patient

3 Insurance Information Please complete information below about your child's insurance coverage. Everything can be found by looking at your current insurance card. Feel free to make a copy of the front and back of your insurance card to include in the packet if you find this easier. Insurance Company's Name Primary Insurance Plan Name Insurance Subscriber's Name Subscriber's Date of Birth Relationship to Patient Employer Group Name Phone Number Subscriber/Member ID Address Listed Group Number Insurance Company's Name Secondary Insurance Plan Name Insurance Subscriber's Name Subscriber's Date of Birth Relationship to Patient Employer Group Name Phone Number Subscriber/Member ID Address Listed Group Number Important Billing & Insurance Information You or your insurance company will receive, at minimum, 2 bills. One bill will be for hospital services rendered as part of your visit (includes facility charge, labs, radiology, & therapies) and the others will be for each doctor your child sees at the visit. Separate co-payments or deductibles for which you are responsible for may be applied to each bill depending on your individual arrangement with your insurance company. If your child sees multiple doctors at your visit, you may be required to pay co-payments for each doctor seen. In some cases, you may receive a bill from your doctor's private office. Please feel free to contact us with any questions.

4 Background and Medical Information Form 1. Background Information Your Child s Primary Doctor: Physician Phone: Pharmacy Phone: Mother: Occupation: Age: Father: Occupation: Age: Who lives in the same home as your child: Reason for visit to the Health4Life Program: What is your main concern? 2. History of Current Problem At what age did weight become a concern? What things have you tried for weight or weight related problems? Please write down any other concerns about your child s health: 3. Past Medical History Immunizations up to date: Medicine Allergies: If yes list: Pregnancy Complications: Food Allergies: If yes list: Birth History: Birth Weight: Premature Birth If : how early? Has your child ever had an operation List: Has your child ever been hospitalized List: Does your CHILD have any of the following conditions: ADHD Anxiety Disorder Asthma Bleeding Disorder Celiac Disease Depression Developmental Delay Diabetes Other Past Medical History: Eczema GI Reflux Heart Disease High Blood Pressure Immunologic Disease Inflammatory Bowel Disease Kidney Disease Learning Disability Liver Disease Migraine Headaches Seasonal Allergies Seizure Disorder Thyroid Disease Please list the other doctors your child sees:

5 Anxiety Disorder ADHD Asthma Cancer/Leukemia Celiac Disease Depression Diabetes Eczema 4. Family History Is there a Family History (i.e Mother, Father, Siblings, Grandparents) of any of the following: Who? Who? Who? Environmental Allergies Gastroesphageal Reflux Heart Disease High Blood Pressure High Cholesterol Immunologic Disease Inflammatory Bowel Disease Joint Disease Kidney Disease Liver Disease Migraine Headaches Seizure Disorder Sudden Death (heart) Thyroid Disease Weight Gain 5. Social History Number of adults in household: Smoking in home: Pets in home: Number of children in household: Ages of children: Is your child in daycare? Is your child in school? Grade: Favorite Activities outside of school: 6. Review of Systems (check all that apply to your child) Constitutional Symptoms Fever Chills Weight Gain/Loss Endocrine Excessive Thirst Too Hot/Cold Tired/Sluggish Frequent Urination Excess Hair Neurological Headaches Dizzy Spells Eyes Blurred Vision Double Vision Cardiovascular Chest Pain Short of Breath Swelling Legs High Blood Pressure Fainting Respiratory Wheezing Frequent Cough Shortness of Breath Sleep Snores a lot Trouble Falling Asleep Sleepy During Day Gastrointestinal Abdominal Pain Nausea/Vomiting Indigestion/heartburn Integumentary (Skin) Skin Rash Boils Persistent Itch Acne Genitourinary Painful Urination Concerns About Penis or Vagina Menstrual Cycle Date of First Period Date of Last Period 7. Please List Your Child s Medications

6 Physical Activity Log Day Type of Physical Activity (i.e. walking, running, play basketball, free play, etc.) Total Minutes of Physical Activity Monday Wednesday Saturday Screen Time Log Day What type of screen time? (TV, video-games, cell-phone texting, computer) Total amount of time (hours) What snacks were eaten during the screen time? Does your child have TV in their room? Monday Wednesday Saturday