Christian Family Medicine and Pediatrics

Clinic Location

Patient Information

Legal Name

Birth/Maiden Name

Gender

Social Security #

Marital Status

Date of Birth

Race

Ethnicity

Preferred Language

Preferred Provider

Religion

Dominant Side

Address

Home Phone

Cell Phone

Work Phone

Email Address of Patient or Guardian

Preferred Contact Method

Preferred Reminder Method

Emergency Contact

Emergency Contact #

Contact's Relationship to Patient

Pharmacy of Choice

Pharmacy City

Pharmacy Phone

Patient Employer

Status

Full Time Part Time

Employer Phone

Student

Yes No

Status

Full Time Part Time

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

Guardian Name

Gender

Date of Birth

Phone Number

Marital Status

Social Security #

Address

Insurance Information

Do you have insurance?

Yes No

Insured Relationship to Patient

Insured Name

Date of Birth

Gender

Social Security #

Marital Status

Address

Phone

Primary Insurance

Insurance Co

Effective Date

Copay Amount

Policy #

Group/Plan #

Policy Holder's Name

Policy Holder's Date of Birth

Policy Holder's Social Security #

Address

Phone

Relationship to Patient

Secondary Insurance

Insurance Co

Effective Date

Copay Amount

Policy #

Group/Plan #

Policy Holder's Name

Date of Birth

Social Security #

Address

Phone

Relationship to Patient

Patient Responsibilities Notification

I have read and understand the financial responsibilities outlined here.

I understand that Christian Family Medicine, Inc. is a Patient-Centered Medical Home facility. Read information about PCMH facility.

I understand that I have been made aware of Christian Family Medicine and Pediatrics Notice of Privacy Practices.

I understand that I have been made aware of Christian Family Medicine and Pediatrics Policy on Access to and Release of Minor's Medical Record.

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.

This information may be released to:

Spouse Children Other Information is not to be released to anyone

Spouse Name

Child(ren) Name(s)

Other

For messages, please call my:

If unable to reach me:

Pediatric Patient Health History

Current Problem

Do you have allergies or intolerance to medications?

Yes No

Please explain...

Do you take any prescription or non-prescription medications. This includes vitamins, supplements, and over the counter pain pills? (Advil, Aleve, Tylenol, etc)

Yes No

Please list ALL of your prescription and non-prescription medicine.

Medication	Dose	How Often?

Please list immunizations and provide date of immunizationYou can also provide a printed record at the time of your appointment.

Immunization	Date

Mammogram

Most recent date

Where?

Abnormal?

Yes No

Pap Smear

Most recent date

Where?

Abnormal?

Yes No

Bone Density Test

Most recent date

Where?

Abnormal?

Yes No

Total # of pregnancies

# of live births

# of miscarriages

# of abortions

Age period started

Age period stopped

Current method of birth control

Hysterectomy

Yes No

Are you currently experience any of the following?

Prostate Issues Erectile Dysfunction Impotence Other

Child's Past Medical History

Where was your child born?

Gestational Age at Birth

Birth Weight

Birth Length

Is the child yours by

Pregnancy Complications

Delivery by

Any problems in the Newborn period

If your child has had immunizations please list ALL facilities your child may have received immunizations.

Social History

Who lives in the household with the child? Choose all that apply

Child's parents are

Childcare

Childcare days per week

Do any household members smoke?

No Yes

How many hours per day does your child

Name of Child's School

Current Grade Level

Any Concerns Regarding Child's Performance at School

No Yes

Sports/Exercise

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

Other Please include anything not listed above.

By checking this box on this online form, I certify that the information I’ve filled out above is correct.

Patient Name

Date

Pediatric New Patient Registration

Primary Insurance

Secondary Insurance

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

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