Patient Information
Parent/Guardian Information Person who is legally responsible for patient, above
Insurance Information

Primary Insurance

$

Secondary Insurance

$
Patient Responsibilities Notification
Patient Disclosure Authorization

Christian Family Medicine Inc. has provided me notification of its Privacy Practice for protected health information.  I authorize Christian Family Medicine, Inc. the release of information including the diagnosis, records; examination rendered to me and claims information.

This Release of Information will remain in effect until terminated by me in writing.

Pediatric Patient Health History
Medication Dose How Often?

Immunization Date

Child's Past Medical History
Social History
Family Medical History

Please indicate which relative has had the following diseases. Write in the number of siblings. For Disease and Conditions, use the comment box provided to list the age your relative got the condition if you know and whether this condition was the cause of death.

Diseases and Conditions

Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased
Alive
Deceased