• CNY FAMILY CARE PEDIATRIC PATIENT INTAKE FORM

    Welcome to CNY Family Care! We are pleased to serve your health care needs and those of your family. To assist our providers and staff, please complete this information to the best of your ability
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  • PARENT #1 INFORMATION

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  • PARENT #2 INFORMATION

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  • HIPAA CONTACT INFORMATION

  • LEGAL GUARDIAN INFORMATION

  • PRIMARY INSURANCE INFORMATION

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  • SECONDARY INSURANCE INFORMATION

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  • 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.
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  • Clear
  • Immunization History

    IMPORTANT: We ask that you attach a copy of your child’s immunization record and return itwith this intake form.
  • ALLERGIES

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  • MEDICATIONS

  • HEALTH MAINTENANCE HISTORY

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  • CHILDHOOD ILLNESS

  • MEDICAL PROBLEMS REVIEW

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  • Child’s Former Primary Care Provider

  • HOSPITALIZATIONS

  • SERIOUS ACCIDENTS OR INJURIES

  • ASSISTIVE DEVICES

    Please indicate if the child currently requires any assistive devices.
  • OBSTETRICS/ GYNECOLOGIC HISTORY

    (For girls only)
  • BIRTH HISTORY

  • FAMILY HISTORY MEDICAL ISSUES

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  • HOME ENVIRONMENT

  • BARRIERS TO CARE

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  • Personal Habits

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

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  • Routine Visit Schedule

    Revised 3/10/2020
  • 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

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