New General Pediatric Patient History- Ages Six To Seventeen Years New General Pediatric Patient History- Ages Six To Eighteen Years New General Pediatric Patient History- Ages Six To Eighteen Years Demographics Child's First Name * Child's Last Name * Child's Street Address * Child's City * Child's State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Child's Zip Code Child's Birthdate * Child's Age (click here) Child's Sex * Female Male Parent Or Other Primary Caretaker First Name * Parent Or Other Primary Caretaker Last Name * Parent Or Other Primary Caretaker Address * Parent Or Other Primary Caretaker City * Parent Or Other Primary Caretaker State * AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Parent Or Other Primary Caretaker Zip Code * Parent Or Other Primary Caretaker Phone * Parent Or Other Primary Caretaker Email * Parent Or Other Primary Caretaker Relationship To Child * Parent Or Step-Parent Grandparent Sister Or Brother Other Family Member Foster Parent Legally Appointed Guardian Other Phone Birth History How Was The Child Born? * Normal Spontaneous Vaginal Delivery Elective Caesarian Section Emergency Caesarian Section Other At How Many Weeks Of Gestation Was The Child Born? * What Was The Child's Birthweight In Pounds And Ounces? * What Was The Child's One Minute Apgar Score? Enter "Unknown" If You Don't Know It. * What Was The Child's Five Minute Apgar Score? Enter "Unknown" If You Don't Know It. * Where There Multiple Births? * One Child Only Twins Triplets Other Were there any complications of the child's birth? Past Medical History List Any Hospitalizations, Including The Child's Age And Reason For Hospitalization. Enter "None" if none. * List Any Surgical Procedures Requiring Anesthesia, Including The Child's Age And The Type Of Surgical Procedure. Enter "None" if none. * List All Of The Child's Prescription Medications (enter "None" if none) * Review Of Systems Has the child had problems with the eyes or vision? (enter "None" if none)* * Has the child had problems with ears and ear infection, if so, how many? (enter "None" if none) Has the child had problems with chronic or recurrent sore throat, if so, how many? (enter "None" if none) Has the child had any heart issues, such as heart murmur or abnormal heart rhythm? (enter "None" if none) * Has the child had problems with chronic cough, asthma, or pneumonia? (enter "None" if none) List All Of The Child's Allergies (enter "None" if none) * Has the child had any stomach, bowel, or digestive issues? (enter "None" if none * Has the child had any neurological issues, such as seizures or developmental delay? (enter "None" if none) * Has the child had any skin issues, such as eczema? (enter "None" if none) * Has the child had urinary or kidney infections or stones or other problems? (enter "None" if none) * Has the child had any other issues not covered above? (enter "None" if none) * Immunization History-List All Immunizations The Child Has Had How Many Doses Of Hepatitis B Vaccine Has The Child Had? 1st Dose (usually at the time of birth 2nd dose (usually at 1-2 months of age) 3rd dose (usually at 6 to 15 months of age) None Don't know How Many Doses Of RSV (Respiratory Syncytial Virus) Vaccine Has The Child Had? 1st Dose (usually at some time between birth and six months of age) 2nd dose (usually at 8-19 months of age) None Don't know How Many Doses Of DTaP (diphtheria, tetanus, acellular pertussis) Vaccine Has The Child Had? * 1st Dose (usually at 2 months of age) 2nd dose (usually at 4 months of age) 3rd dose (usually at 6 months of age) 4th dose (usually at 15 months of age) 5th dose (usually at 4-6 years of age) None Don't know How Many Doses Of Tdap (diphtheria, tetanus, acellular pertussis) Vaccine Has The Child Had? * 1st Dose (usually at 11-12 years age) None Don't know How Many Doses Of Rotavirus Vaccine Has The Child Had? * 1st Dose (usually at 2 months of age) 2nd dose (usually at 4 months of age) 3rd dose (usually at 6 months of age) None Don't know How Many Doses Of HiB (hemophilus influenza type b) Vaccine Has The Child Had? * 1st dose (usually given at 2 months of age) 2nd dose (usually given at 4 months of age) 3rd dose (sometimes given at 6-15 months of age) 4th dose (sometimes given at 12-15 months of age) None Don't know How Many Doses Of Pneumococcal Vaccine Has The Child Had? * 1st dose (usually given at 2 months of age) 2nd dose (usually given at 4 months of age) 3rd dose (usually given at 6 months of age) 4th dose (usually given at 12-15 months of age) None Don't know How Many Doses Of Inactivated Polio Vaccine Has The Child Had? * 1st dose (usually given at 2 months of age) 2nd dose (usually given at 4 months of age) 3rd dose (usually given at 6-18 months of age) 4th dose (usually given at 4-6 years of age) None Don't know How Many Doses Of Measles, Mumps, Rubella Vaccine Has The Child Had? * 1st dose (usually given at 12-15 months of age) 2nd dose (usually given at 4-6 years of age) None Don't know How Many Doses Of Varicella (chickenpox) Vaccine Has The Child Had? * 1st dose (usually given at 12-15 months of age) 2nd dose (usually given at 4-6 years of age) None Don't know How Many Doses Of Hepatitis A Vaccine Has The Child Had? * 1st dose (usually given at 12-15 months of age) 2nd dose (usually given at 12-24 months of age) None Don't know How Many Doses Of Human Papilloma Virus (HPV) Vaccine Has The Child Had? * 1st dose (usually given at 11-12 years of age) None Don't know How Many Doses Of Meningococcal Vaccine Has The Child Had? * 1st dose (usually given at 121-12 years of age) None Don't know Dietary History What Foods Does The Child Take Each Day? Check All That Apply. * Whole milk Low-fat milk Skim milk Protein (meat, fish) Breads, Cereals Fruits Green/yellow vegetables Other Does the child seems overweight or underweight to you? * Underweight Overweight Neither underweight or overweight Does The Child Take Any Dietary Or Nutritional Supplements? Are There Any Foods The Child Does Not Tolerate, Such As Milk Or Wheat? * Do You Have Any Dietary Or Activity Questions Or Concerns? Enter "None" If You Have No Such Concerns. * Social History School Attended * Public School Private School Charter School Parent Co-op School Home School Not Attending School At This Time What Grade Of School Is The Child Now In? * What Are The Child's Favorite Subjects In School? * Are There Subjects In School That Are Hard For The Child? * Does The Child Receive Special Education Services At School? * No Yes Please Describe The Special Education Services The Child Receives At School Does The Child Live With Both Natural Parents? Yes No Is Either Parent Deceased? No Mother is deceased Father is deceased How Has Legal Custody Of The Child? Check all that apply? Mother Father Step-mother Step-father Other Family Member Unrelated Person(s) Who Is/Are The Child’s Primary Caretakers? Check All That Apply. At home mother Mother working outside the home full-time Mother working outside the home part-time At home father Father working outside the home full-time Father working outside the home part-time Other family member part-time Other family member full-time Non-family member full-time Non-family member part-time Please Briefly Describe The Child's Living/Custody Arrangements Is The Child's Father Currently Employed? Employed outside the home Employed at home Employed, working both at home and outside the home Not employed at this time Briefly, What Kind Of Work Does The Child's Father Usually Do For Employment When Employed? Is The Child's Mother Currently Employed? Employed outside the home Employed at home Employed, working both at home and outside the home Not employed at this time Briefly, What Kind Of Work Does The Child's Mother Usually Do For Employment When Employed? Do You Have Any Concerns That The Child Is Being Physically, Emotionally, Or Sexually Abused By Anyone? * No Yes Possibly Please Describe Your Concerns Does The Child Wear A Helmet When Riding A Bicycle? Yes, always Yes, sometimes Not usually Never Does The Home Have All Required Smoke And Carbon Monoxide Detectors Installed? Yes No If There Are Any Firearms Or Ammunition In The Home, Are They Properly Secured? No firearms or ammunition in the home Firearms or ammunition present but secured Firearms or ammunition present, not secured Family History Does The Child Have Any Living Siblings (brothers or sisters)? Yes No Please Briefly Describe The Child's Living Siblings By Age, Sex, And Any Health Issues Does The Child Have Any Deceased Siblings (brothers or sisters)? Yes No Please Briefly Describe The Child's Deceased Siblings By Age, Sex, And Principal Cause Of Death Please Briefly Describe The Ages And Health Of The Child's Parents * Please Briefly Describe The Ages And Health Of The Child's Grandparents Or, If Deceased, Their Ages At The Time Of Death And The Principal Cause Of Death * Are There Any Diseases That Seem To Run In The Family? If Not, Enter "None" * Do You Have Any Other Comments Or Questions Or Is There Anything Else That You Wish To Mention? Notices And Permissions I authorize BayCare Medical Group to treat my child for pediatric care Yes I authorize BayCare Medical Group to file health plan claims on my behalf Yes Communication Authorization: I authorize BayCare Medical Group And Its Doctors To Communicate With Me Regarding The Child's Care By Telephone, Text Message, or Email Yes Required HIPPA Privacy Practices Notice: * Click here to see our HIPPA Practices Notice Click here to skip our HIPPA Practices Notice HIPPA Notice-BayCare, 4-18-2024 Required Medical Board of California Notice To Consumers: Richard B. Fox, M.D.,J.D., CA Medical License #G67169 provides this NOTICE TO CONSUMERS: Medical doctors are licensed and regulated by the Medical Board of California (800) 633-2322, www.mbc.ca.gov. Click "yes" to acknowledge receipt of this legally required notice. * Yes Name Of Person Submitting This Information: Date Submitted File Name Captcha If you are human, leave this field blank. Submit
