Child New Patient Intake Form

Child New Patient Intake Form

Complete this before your appointment and your provider can be better prepared during their time with you.
Patient Information

This information will be sent to your provider and will be kept as part of your patient records.
Name*

First NameLast Name
Nickname*
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother's Name*
Father's Name*
Emergency contact: *
Phone number:*
How did you hear about our office?*
Current Health Condition
Primary Complaint*
When did this condition begin?*
Has it occurred before?*

YesNo
First time ever experienced?*
Was it an accident or trauma?*

YesNo
If yes, please explain
How does it feel?*

SharpDullAchingThrobbingCrushingStabbingBurningOther
Is there anything that makes it better?*
Is there anything that makes it worse?*
What solutions have you tried to solve this problem?*
Please choose your level of pain (0=no pain, 10=disabling pain)
Does it radiate into the arms or legs?

YesNo
Is there any numbness or tingling?

YesNo
Are the symptoms:

Constant (75-100% of the time)Frequent (50-75% of the time)Occasional (25-50% of the time)Infrequent (0-25% of the time)
Are the symptoms worse in:

MorningMiddayNightConsistent all day
What activity(s) does this prevent the child from doing either partially or totally they that they would like to be able to do again?*
What area(s) of life has this affected most?*

SchoolSportsActivities with family/friendsSleepOther
What does the child do in a typical day?*
What other health problems concern you today?
What would be your #1 goal from visiting this clinic?*
Past Medical History
Please give a brief description of any significant injuries or accidents over the course of the child's life. (sports injuries, auto accidents, slips and falls, concussions, broken bones, etc. and approximate dates)
Any problems during pregnancy?
Any problems during labor/delivery?
Type of birth

VaginalCesareanBreachHomeHospital
Please check any of the following the child has suffered from:

Lack of energyFocus/concentrationSleep problemsSinus/allergy problemsDigestive problemsPoor appetiteFrequent coldsTension/stressDepressionAnxietyEar infectionsBed WettingBehavioral problemsHeadachesWalking problemsJoint problemsGrowing painsStomach achesScoliosisHeart conditionCancerDiabetesOther
Please list any surgeries over the course of the child's life (with approximate dates):
Any allergies to medication? If so, what medication(s)?
List any medications the child is currently taking:*
Consent to Treat Minor
I hereby authorize Genesis Integrative Medicine, LLC and any providers employed therein to administer treatment as deemed necessary to my child.
Signature of Parent or Guardian*

Clear
Date*

MonthDayYear
Date
Release of Information
This is confidential record of my medical history and pertinent personal information. The doctor/nurse practitioner reserves the right to discuss this information with medical and allied health professionals per this informed consent. Copies of this record can only be released by your written authorization. Copies of this record can only be released by your written authorization.
Signature*

Clear
Date*

MonthDayYear
Date
Informed Consent for Treatment/Diagnostic Imaging
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I certify that I am the patient or legal guardian of the above listed patient. I authorize this office and its staff to examine and treat my condition as the medical professionals see fit, including having diagnostic x-ray examination if necessary.
Signature*

Clear
Date*

MonthDayYear
Date
Insurance Information
Primary Insurance Company
Subscriber ID
Group ID
Name and Date of Birth of Primary Account Holder
Insurance Card (Front)

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Insurance Card (Back)

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Should be Empty:

Child New Patient Intake Form

Patient Information

Current Health Condition

Past Medical History

Consent to Treat Minor

Release of Information

Informed Consent for Treatment/Diagnostic Imaging

Insurance Information