Cnyfamilycare - ADOLESCENT NEW PATIENT HISTORY FORM

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Please enter a valid phone number.

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Please enter a valid phone number.

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Please enter a valid phone number.

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Please enter a valid phone number.

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

The above information is accurate to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance not covered by insurance. I also authorize CNY Family Care or the insurance company to release any information required to process claims.

	Yes	No
Iodine or X-ray contrast dye
Latex
Bee or Wasp Stings
Adhesive Tape

	Unknown	Yes	No	Date	Where
Dental Exam
Eye Exam
Routine Physical Exam
Lead Test

	Yes	No	Describe the problem when appropriate
ADHD / HDD
Allergies
Ear Infections (recurrent)
Developmental Problems
Diabetes
Joint Disorder
Mental Illness
Mononucleosis
Sexually transmitted disease(s)
Treatment for alcohol and/or drug use

	No Problem	Medical Problem	Had Surgery	Year(s)	Describe the problem	Type of surgery
Eyes
Ears, nose, sinuses, tonsils (tubes)
Thyroid or parathyroid glands
Coronary (heart), heart arteries, heart valves, heart rhythm
Arteries (aorta, arteries to head, arms, legs)
Veins, blood clots in the veins
Lungs (asthma)
Esophagus or stomach (ulcer, reflux)
Bowel (small & large intestine)
Appendix, Intestinal Disorder)
Liver or gall bladder (including Hepatitis)
Hernia
Kidneys or bladder (urinary disorder)
Bones, joints, muscles, back neck, spine
Brain (seizure disorder, Meningitis)
Skin (eczema, acne)
FEMALES: uterus, tubes, ovaries
MALE: prostate, penis, testes, vasectomy

Please enter a valid phone number.

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Immunized Not Immunized

Yes, If known, complete the following information below about the child’s blood relatives. Exclude adoptive parents and siblings No

	Father	Mother	Brothers	Sisters	Paternal Grandmother	Paternal Grandfather	Maternal Grandmother	Maternal Grandfather	None	Describe
Immune Problems, HIV, AIDS
Alcoholism
Addiction - Drugs
Anemia
Arthritis (childhood) (JRA)
Birth Defects
Bleeding/Clotting Disorder
Crohn's or ulcerative colitis
Developmental Delay
Diabetes
Epilepsy or Convulsions
Heart Disease (before 50 years old)
High Blood Pressure (Before age 50)
Kidney Disease
Liver Disease
Mental Illness
Intellectual Disability (Mental Retardation)
Thyroid Disease

Apartment Car Friend's Home Relative's Home Group Home House Trailer Homeless - living on the street Homeless - staying in a shelter

Prefer Not to Answer No Yes, locked up Yes, not locked up

Daycare Elementary High School Home school None

Cognitive ability impaired Deafness-complete Hearing impaired Impaired memory Unable to read Unable to understand when he/she reads Vision Impaired None Identified – The child does not have any barriers to learning Other

Head Start Program Day Service Program Home Care Occupational Therapy Physical Therapy No - Child does not receive any services Other

No Yes - Bullying in school Yes - Domestic Violence Yes - Emotional abuse Yes - Physical abuse Yes - Sexually abused

No, Generally Healthy, Well Balanced Yes, specify

	Dependent	Independent	Requires Assistance
Ambulating
Bathing
Cooking
Cleaning
Dressing
Grooming
Laundry
Meds
Money
Shopping
Standing
Telephone
Toileting

Energy drinks Coffee Chocolate Iced Tea

Always Sometimes Never

Always Sometimes Never N/A

3-5 DAYS OLD (24-48 hours after hospital discharge): WEIGHT/JAUNDICE CHECK

(2 WEEK VISIT: NOT ROUTINE – FOR SICK NEWBORN CHECKUPS ONLY)

2 MONTH VISIT: GROWTH & DEVELOPMENT CHECK, IMMUNIZATIONS, POSTNATAL SCREEN

4 MONTH VISIT: GROWTH & DEVELOPMENT CHECK, IMMUNIZATIONS, POSTNATAL SCREEN

6 MONTH VISIT: GROWTH & DEVELOPMENT CHECK, IMMUNIZATIONS

9 MONTH VISIT: GROWTH & DEVELOPMENT CHECK, VISION CHECK

12 MONTH VISIT: GROWTH & DEVELOPMENT CHECK, SCREEN FOR TB, HEMOGLOBIN/LEAD LEVEL, IMMUNIZATIONS

15 MONTH VISIT: GROWTH & DEVELOPMENT CHECK, IMMUNIZATIONS

18 MONTH VISIT: GROWTH & DEVELOPMENT CHECK, IMMUNIZATIONS, HEMOGLOBIN LEVEL IF NECESSARY

2 YEARS: GROWTH & DEVELOPMENT CHECK, SCREEN TB, HEMOGLOBIN/LEAD LEVEL, VISION CHECK

3-4 YEARS: GROWTH & DEVELOPMENT CHECK, SCREEN FOR TB, VISION CHECK, HEARING SCREEN, LEAD SCREEN AS NEEDED

5 YEARS: GROWTH & DEVELOPMENT CHECK, SCREEN FOR TB, IMMUNIZATIONS, VISION CHECK, LEAD SCREEN AS NEEDED

6-10 YEARS: GROWTH & DEVELOPMENT CHECK, SCREEN FOR TB, VISION CHECK, MAKE UP IMMUNIZATIONS IF NECESSARY, LEAD SCREEN AS NEEDED

11 YEARS: GROWTH & DEVELOPMENT CHECK, SCREEN FOR TB, VISION CHECK, IMMUNIZATIONS, LIPID PANEL

12-18 YEARS: GROWTH & DEVELOPMENT CHECK, SCREEN FOR TB, VISION CHECK, CARDIAC SCREEN, MAKEUP IMMUNIZATIONS AS NECESSARY, ADOLESCENT SCREENS

19-21 YEARS: GROWTH & DEVELOPMENT CHECK, SCREEN FOR TB, VISION CHECK, CARDIAC SCREEN, MAKE UP IMMUNIZATIONS AS NECESSARY, ADOLESCENT SCREENS, TRANSFER TO ADULT PHYSICIAN

CNY FAMILY CARE PEDIATRIC PATIENT INTAKE FORM

PARENT #1 INFORMATION

PARENT #2 INFORMATION

HIPAA CONTACT INFORMATION

LEGAL GUARDIAN INFORMATION

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

Immunization History

ALLERGIES

MEDICATIONS

HEALTH MAINTENANCE HISTORY

CHILDHOOD ILLNESS

MEDICAL PROBLEMS REVIEW

Child’s Former Primary Care Provider

HOSPITALIZATIONS

SERIOUS ACCIDENTS OR INJURIES

ASSISTIVE DEVICES

OBSTETRICS/ GYNECOLOGIC HISTORY

BIRTH HISTORY

FAMILY HISTORY MEDICAL ISSUES

HOME ENVIRONMENT

BARRIERS TO CARE

Personal Habits

I have completed this Pediatric Intake Form to the best of my ability

Routine Visit Schedule