Pediatric Scholar Intake Form

Does your child currently have a doctor/pediatrician?

Yes

If yes, what is their name and phone number?

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Which way would you prefer our clinic contact you on behalf of your child?

If you would like us to communicate with you via a phone number or email that is different than listed above, please enter it here:

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What are your child's most important health concerns? Please list any health concerns or symptoms:

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Please describe if there are any accommodations our clinic can make for you or your child(for example, magnifying glasses if you are visually impaired, assistance with filling out forms, dimming fluorescent lighting, etc.):

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Would you like a medical interpreter?

Yes

If yes, what language?

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What is your child's race or family background?

Black/African/African-American

Latino

Pacific Islander

Asian

White

Decline to identify

American Indian/Alaska Native/Native Hawaiian/Enrolled Citizen- please list tribe below

Prefer to self describe- please type in below

Describe/put more detail here if you would like:

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Is your family 1st or 2nd generation immigrants or refugees?

Yes

When was your child's last annual well visit/physical exam?

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Is your child an athlete?

Yes

N/A

Does your child have an IEP or 504 plan?

Do your child have any allergies?

Yes

Unsure

Please list any allergies to drugs, foods, or environmental factors and your child's reactions below:

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Does your child take any of the following medications? If yes, please check them below:

No to all

Yes

Pain relievers (aspirin, ibuprofen, Tylenol, etc)

Asthma medication/inhalers

Cortisone (creams or pills)

Antibiotics

Allergy medications

Decongestants

Sleep medications

Acid reflux medications

Stooling medications

Is your child currently taking any prescription medications, over-the-counter medications, vitamins or other nutritional/herbal supplements?

Yes

If yes, please list them below:

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What hospitalizations, surgeries, injuries, accidents, or serious illnesses has your child had?

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Has your child had any immunization? Please check below (or provide a copy of vaccine record):

Pneumococcal (PCV)

Tdap

Meningitis (MCV)

MMR

Polio

Hep A

Hep B

Influenza

HPV

Mother's age at child's birth?

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Baby's birth weight

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Did mother's health history during pregancy and birth include any of the following?

bleeding

nausea

high blood pressure

diabetes

thyroid problems

stress

cigaratte, alcohol, or drug use

physical or emotional trauma

Other- please describe:

Was/is your child breast fed?

If yes, for how long?

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Many families are having a hard time. Are there additional life stressors on your family? Please check below if so.

Housing

Food

Legal/court system

Racial discrimination

Domestic violence

Employment

Medical issues in the family

Other- please describe:

Do your child a personal or family history of the following?

No to all

Yes- please select all that apply

Anemia

Damaged heart valve

Arthritis

Asthma

Hay fever/hives

Stroke

Kidney disease

Cancer

Heart disease

Mental disorder

Thyroid problems

Diabetes

High blood pressure

Sickle cell disease

Hepatitis

Liver disease

Tuberculosis

HIV

Other major disease- please describe:

Do your child have any of the following symptoms/conditions?

No to all

Yes - please check below

Cold hands/feet

Numbness/tingling

Muscle aches

Neck pain/stiffness

Back pain or sciatica

Shooting pain

Burning pain

Migraines or headaches

Heart murmur

Congenital disorder

Stomach aches

Anxiety or depression

ADHD

Autism

Low blood pressure

Frequent colds

Easy bruising/bleeding

Night Sweats

Bed wetting

Frequent urination

Skin rashes/eczema

Loss of hair

Diarrhea

Constipation

Heartburn

Fainting

Chest pain

Weakness

Cramping

Joint pain

Sore throat

Strep throat

Fever

Cough

Shortness of breath

Asthma

Croup

Fatigue

Dizziness

Seizures

Jaw pain

Ear aches

Ear infections

Itching

Acne

Eye problems

Sinus problems

Head injury

Paralysis

Blood in stool

Ulcers

Sleep problems

Stress/irritability

Chicken pox

Rheumatic fever

Scarlet fever

Other- please describe:

Have any imaging/special studies been done?

CT scan

ECG/EKG

EEG

Hearing

MRI

Psych eval

Reading/writing

Speech/language

X-ray

Other- please describe:

What is your child's favorite thing to do?

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Does your child spend time outdoors daily?

Is/has your child been exposed to secondhand smoke?

If yes, for how long?

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Does your child drink soda/eat refined sugar regularly?

Does your child watch TV?

If yes, for how many hours?

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Does your child read?

If yes, for how many hours?

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Does your child use social media?

If yes, for how many hours?

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Are you generally concerned about the cost of medical bills and/or copays?

Yes

Do you have health insurance?

Yes- please fill out more info below

In the next section, if you are unsure of what insurance your child has or which policy it is, please choose "other" in the drop down menu and write "unknown" under policy

Insurer

Policy Name

Policy / Group / Plan #

Member ID / Certificate #

Policy Holder

I'm not the policy holder.

First Name

Last Name

Relationship To Patient

Date of Birth

Address

City

Prov / State

Postal / Zip Code

Phone Number

Do you have dental insurance?

What is the name of your dental insurance?

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What is the policy number for your dental insurance?

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