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 Sex
Parent Or Other Primary Caretaker Relationship To Child

Birth History

How Was The Child Born?
Where There Multiple Births?

Past Medical History

Review Of Systems

Immunization History-List All Immunizations The Child Has Had

How Many Doses Of Hepatitis B Vaccine Has The Child Had?
How Many Doses Of RSV (Respiratory Syncytial Virus) Vaccine Has The Child Had?
How Many Doses Of DTaP (diphtheria, tetanus, acellular pertussis) Vaccine Has The Child Had?
How Many Doses Of Tdap (diphtheria, tetanus, acellular pertussis) Vaccine Has The Child Had?
How Many Doses Of Rotavirus Vaccine Has The Child Had?
How Many Doses Of HiB (hemophilus influenza type b) Vaccine Has The Child Had?
How Many Doses Of Pneumococcal Vaccine Has The Child Had?
How Many Doses Of Inactivated Polio Vaccine Has The Child Had?
How Many Doses Of Measles, Mumps, Rubella Vaccine Has The Child Had?
How Many Doses Of Varicella (chickenpox) Vaccine Has The Child Had?
How Many Doses Of Hepatitis A Vaccine Has The Child Had?
How Many Doses Of Human Papilloma Virus (HPV) Vaccine Has The Child Had?
How Many Doses Of Meningococcal Vaccine Has The Child Had?

Dietary History

What Foods Does The Child Take Each Day? Check All That Apply.
Does the child seems overweight or underweight to you?

Social History

School Attended
Does The Child Receive Special Education Services At School?
Does The Child Live With Both Natural Parents?
Is Either Parent Deceased?
How Has Legal Custody Of The Child? Check all that apply?
Who Is/Are The Child’s Primary Caretakers? Check All That Apply.
Is The Child's Father Currently Employed?
Is The Child's Mother Currently Employed?
Do You Have Any Concerns That The Child Is Being Physically, Emotionally, Or Sexually Abused By Anyone?
Does The Child Wear A Helmet When Riding A Bicycle?
Does The Home Have All Required Smoke And Carbon Monoxide Detectors Installed?
If There Are Any Firearms Or Ammunition In The Home, Are They Properly Secured?

Family History

Does The Child Have Any Living Siblings (brothers or sisters)?
Does The Child Have Any Deceased Siblings (brothers or sisters)?

Maximum file size: 25MB

Notices And Permissions

I authorize BayCare Medical Group to treat my child for pediatric care
I authorize BayCare Medical Group to file health plan claims on my behalf
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
Required HIPPA Privacy Practices Notice:
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.
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