Complete New Patient Paperwork Online! Visit epic ......Diet: (0-24 months) Breastfed: Yes No Vitamin Supplement: Yes No Formula: Yes No Diet: (24 months-11 years) Breastfed Age Appropriate

Page 1 of 6

Pediatric Patient Information (0-11 years old)PG-2003 rev. 04/17

PATIENT INFORMATION

Name: ___________________________________________________________________________________ SSN: _________________________________________ Last First MI

Sex: M F DOB: __________________________ Preferred Name: ____________________________________________________________________

Address: __________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________ City State ZipMailing address: Check if same as above____________________________________________________________________________________________________________________________________________ Address

____________________________________________________________________________________________________________________________________________ City State Zip

Home Phone: ______________________________________________________ Cell: ________________________________________________________________

Would you prefer to speak to your healthcare provider through a translator? Yes No

Preferred Language: English Other (please specify): __________________________ Written Language: _________________________Religion: _______________________________________________ Declined Birthplace: ___________________________________________________Ethnicity: Do you consider yourself to be Hispanic or Latino? Yes No DeclinedRace: American Indian or Alaska Native Native Hawaiian or other Pacific Islander White Black or African American Asian DeclinedPHARMACY Address/Cross Streets Phone Number PreferredLocal: __________________________________ ______________________________________________________ __________________________ Alternative: ____________________________ ______________________________________________________ __________________________ Mail Order: ____________________________ ______________________________________________________ __________________________ CARE TEAM

Primary Care Provider: ___________________________________________________________________ Phone Number: ___________________________

Specialist Name: _______________________________ Specialty: _______________________________ Phone Number: ___________________________

Specialist Name: _______________________________ Specialty: _______________________________ Phone Number: ___________________________

Complete New Patient Paperwork Online! Visit epic.mycenturahealth.org to complete your Health History Questionnaire and update your information.

EMERGENCY CONTACT

Name: ______________________________________________________________ Relation to patient: _______________________________________________ Last FirstAddress: _______________________________________________________________________________________________________________________________

Phone: ______________________________________________________

Name: ______________________________________________________________ Relation to patient: _______________________________________________ Last FirstAddress: __________________________________________________________________________________________________________________________________

Phone: ______________________________________________________

Yes No Legal Guardian:

Yes No Legal Guardian:

Page 2 of 6

Pediatric Patient Information (0-11 years old)PG-2003 rev. 03/17

Advance DirectiveDo you have a Living Will / DNR? Yes NoDo you have a Durable Power of Attorney? Yes NoIf yes: ____________________________________________________________________________________________________________________________________ Please Print Name Phone NumberWould you like information regarding Advance Directive? Yes No

SUBSCRIBER INFORMATIONName: __________________________________________________________________________________________ DOB: ___________________________________ Last First mm/dd/yyAddress: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ City State ZipPhone: _____________________________________________ SSN: _______________________________________________ Relation to patient: ________________________________________________________________Employer: _______________________________________________

MEDICATIONS NonePlease list any medications you are taking (including aspirin, vitamins, supplements or any other over the counter medication). Name of Medication Dose How often do you take Reason for taking medication

Chief Complaint (Reason for Visit): _____________________________________________________________________________________________________________________

ALLERGIES No Known Drug Allergies Medication: ___________________________________________________ Reaction: ______________________________________________________________ Medication: ___________________________________________________ Reaction: ______________________________________________________________

Other (latex, adhesive, food, environment): ________________________________________________________________________

Medication: ___________________________________________________ Reaction: ______________________________________________________________Other (latex, adhesive, food, environment): ________________________________________________________________________

Full Time/Part Time: _______________________________________________

Page 3 of 6

Pediatric Patient Information (0-11 years old)PG-2003 rev. 03/17

PERSONAL MEDICAL HISTORYPlease check all diagnoses that apply to you and add notes as needed.

AIDS Yes NoAnemia, Type: _________________________________________ Yes NoAsthma Yes NoBleeding / Clotting disorder Yes NoChronic Pain Yes NoCongenitial Yes NoConstipation Yes NoDiabetes, Type: _______________________________________ Yes NoDisabilities: ____________________________________________ Yes NoEar Infection, recurrent Yes NoEnvironmental/Food Allergies: _______________________ Yes NoGERD (Reflux) Yes NoHead Injury/Concussion Yes NoHearing Deficit Yes NoHIV Yes NoLong-Term Steroid Use Yes No

Oxygen Use Yes NoPneumonia, recurrent Yes NoScoliosis Yes NoSeasonal Allergies: ___________________________________ Yes NoSeizures, Type: ________________________________________ Yes NoSnoring Yes NoThroat infection, recurrent Yes NoThyroid Problems Yes NoTuberculosis exposure Yes NoUTI (Bladder infections) Yes NoOther Conditions: _____________________________________ Yes No_________________________________________________________ _________________________________________________________ _________________________________________________________ Date of last dental exam: ____________________________ Date of last vision exam: _____________________________

BIRTH HISTORY Hospital of Delivery? ________________________________________________________________________________________________________________

(Name) (City, State/Zip)Birth Weight: __________________________ Weeks Pregnant (Gestational age): _______________________________________________________Complications with Pregnancy/Delivery/Hospital Stay? Yes NoExplain if ✓ Yes: ________________________________________________________________________________________________________________________Hearing Screen passed in hospital? Yes No Don't Know

PATIENT INFORMATIONName: ___________________________________________________________________________________ DOB: _________________________________________ Last First MI

Page 4 of 6

Pediatric Patient Information (0-11 years old)PG-2003 rev. 03/17

Have you ever had a reaction to general anesthesia? Yes NoAdditional Personal Medical History________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Tobacco Use: Second hand smoke exposure No second hand smoke exposure

SOCIAL HISTORY (Complete for current age)Diet: (0-24 months)Breastfed: Yes NoVitamin Supplement: Yes NoFormula: Yes No

Diet: (24 months-11 years) Breastfed Age Appropriate Vegetarian High Fat/Calorie Intake Other

Exercise/Activity Level: Sedentary Strength/Wt. Training Active Twenty minutes/day exercise Exercise three times weekly Aerobic/Cardiac

SURGICAL HISTORYPlease list surgeries/procedures and add notes as needed.

Year Surgery/Procedure Hospital/Location Complications/Additional Comments

Name: _______________________________________________________________________________________________________ DOB: ______________________________________ Last First MI mm/dd/yyyy

Page 5 of 6

Pediatric Patient Information (0-11 years old)PG-2003 rev. 03/17

PLEASE USE THIS SPACE FOR ANY ADDITIONAL INFORMATION

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

With whom do you live? Mom Dad Both Parents Sibling Other: ____________________________________________

Education: Day Care (name): ________________________________________________ Grade School: (current grade) __________________

In the last 30 days, have you traveled to any foreign countries? Yes No List: _______________________________

Do you: Use seatbelts Use a helmet Have guns in home Have smoke detector in home Car Seat/Booster

Concerns about learning or development skills (specify): ____________________________________________________________________________

Concerns about behavior or social skills (specify): ___________________________________________________________________________________

How many hours of screen time/day: _____________________

IMMUNIZATIONS All Immunizations current Unknown

Please provide any known dates or full immunization record(s).

Name: _______________________________________________________________________________________________________ DOB: ______________________________________ Last First MI mm/dd/yyyy

Page 6 of 6

Pediatric Patient Information (0-11 years old)PG-2003 rev. 03/17

FAMILY HISTORYWhat illnesses/conditions/diagnoses are in your family? Indicate the age of diagnosis in the boxes below, if known.

Name: _______________________________________________________________________________________________________ DOB: ______________________________________ Last First MI mm/dd/yyyy

Alcohol a

buse

Asthma

Blood clots

Breast

cance

r

Colon cance

r

Prostate

cance

r

Other ca

ncer(s

)

Demen

tia

Diabete

s

Heart

diseas

e

High blood pressu

re

High choles

terol

Kidney dise

ase

Liver d

iseas

e

Lung diseas

e

Mental

Illnes

s

Stroke

Thyroid co

ndition(s)

Other:___

______

Ovaria

n Can

cer

Other:___

_____

Other:___

______

No Known Problems

Mother

Father

Sister

Brother

Son

Daughter

Other:_______

Other:_______

Other:_______

Relationship Name Status

Maternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal Grandfather

Page 1 of 1

Review of SystemsPG-2001 rev. 08/16

Patient Label

Please check any symptoms you've experienced over the LAST ONE TO TWO WEEKS:

_________________________________________________________________________________ _________________________________________________________________________ ____________________________________ Patient or Guardian Name (please print) Patient or Guardian Signature Date

General/ Constitution Activity Change Appetite Change Chills Diaphoresis (Sweating) Fatigue Fever Irritability Unexpected Weight Change

Ear, Nose & Throat Congestion Dental Problems Drooling Ear Discharge Ear Pain Facial Swelling Hearing Loss Mouth Sores Nosebleeds Postnasal Drip Rhinorrhea (Runny Nose) Sinus Pressure Sneezing Sore Throat Tinnitus (Ringing in the Ears) Trouble Swallowing Voice Change

Eyes Eye Discharge Eye Itching Eye Pain Eye Redness Photophobia (Sensitivity to Light) Visual Disturbance (Blurred Vision)

Respiratory Apnea Chest Tightness Choking Cough Shortness of Breath Stridor (Airway Obstruction) Wheezing

Cardiovascular Chest Pain Leg Swelling Palpitations (Irregular Heart Beat)

Gastrointestinal Abdominal Distention (Bloating) Abdominal Pain Anal Bleeding Blood in Stool Constipation Diarrhea Nausea Rectal Pain Vomiting

Endocrine Cold Intolerance Heat Intolerance Polydipsia (Abnormal Thirst) Polyphagia (Abnormal Hunger) Polyuria (Abnormal Urination)

Genitourinary Difficulty Urinating Dysuria (Painful Urination) Enuresis (Involuntary Urination) Flank Pain (Low Back Pain) Frequency Change (Urinary) Genital Sores Hematuria (Blood in Urine) Menstrual Problems Pelvic Pain Penile Discharge Penile Pain Penile Swelling Scrotal Swelling Testicular Pain Urinary Urgency Changes in Urine Stream Vaginal Bleeding Vaginal Discharge Vaginal Pain

Musculoskeletal Arthralgias (Joint Pain) Back Pain Gait Problems Joint Swelling Myalgias (Muscle Pain) Neck Pain Neck Stiffness

Skin Color Change Pallor (Paleness) Rash Wounds

Allergy/Immunologic Environmental Allergies Food Allergies Immunocompromised

Neurologic Dizziness Facial Asymmetry Headache(s) Light Headedness Numbness Seizures Speech Difficulty Syncope (Loss of Consciousness) Tremors Weakness

Hematologic Adenopathy (Swollen Glands) Bruising Tendency Bleeding Tendency

Behavioral Agitation Behavioral Problems Confusion Decreased Concentration Dysphoric Mood (Mood Changes) Hallucinations Hyperactive Nervousness Anxiety Self Injury Sleep Disturbance Suicidal Thoughts

Any other symptoms: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________