Pediatric Scholar Intake Form

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:

Characters: 0/255

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

Characters: 0/255

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.):

Characters: 0/255

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

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

Characters: 0/255

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

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

Characters: 0/255

Pneumococcal (PCV)

Tdap

Meningitis (MCV)

MMR

Polio

Hep A

Hep B

Influenza

HPV

bleeding

nausea

high blood pressure

diabetes

thyroid problems

stress

cigaratte, alcohol, or drug use

physical or emotional trauma

Other- please describe:

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

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