Pediatric Registration Packet

Patient Information
Patient Name*
First Middle Last
Address Where the Child Lives*
Street Address Address Line 2 City State ZIP Code
Patient's Date of Birth*
MM slash DD slash YYYY
Patient's SSN*
Patient's Gender
- Male
- Female
Are the patient's parent's divorced?*
- Yes
- No
Who is the custodial parent? (Which parent does the child spend most of their time with?)*
Which parent carries the insurance benefits? (Guarantor)*
What is the Guarantor's date of birth?*
MM slash DD slash YYYY
Guarantor Mailing Address*
Street Address Address Line 2 City State ZIP Code
Is the guarantor's physical address different from the mailing address?*
- Yes
- No
Guarantor's Physical Address*
Street Address Address Line 2 City State ZIP Code
Guarantor's Home Phone*
Guarantor's Cell Phone*
Guarantor's Email*
Patient Portal*
- Yes
- No
Is the patient currently a minor? (Under the age of 18)*
- Yes
- No
Please list:*
Name of parent / head of household Parent / guarantor of Birth Phone Number (if different)
Guarantor's Employer*
Guarantor's Work Phone
In Case of Emergency
Emergency contact information*
Name of Contact Phone Number Relationship to Patient
Person who can call and receive patient medical information: (for confidentiality purposes)
Name of Contact Phone Number Relationship to Patient
Insurance Information
Who is your primary medical provider?*
Name of Insurance Policyholder?*
Birth-Date of Policyholder*
MM slash DD slash YYYY
SSN of the Policyholder (required by insurance carrier)*
Relationship of Policyholder to Patient?
Policy ID Number*
Group Number*
Deductible or Co-Pay Amount
Deductible Co-Pay
Do you have secondary insurance?*
- Yes
- No
Name of Secondary Primary Insurance*
Name of Secondary Insurance Policyholder*
Birth-Date of Policy Holder*
MM slash DD slash YYYY
SSN of Policyholder*
Relationship of Policy Holder to Patient
Policy ID Number*
Group Number*
Deductible or Co-Pay Amount
Deductible Co-Pay
Patient Info (Child)
Child's Info
Child's Name Child's Date of Birth Current Age Child's Gender
The child's parents are*
- Single
- Married
- Divorced
- Separated but not divorced
- Widowed
- Living together but not married
Is your child adopted?
- Yes
- No
If yes, at what age?*
Please list your child's main health problems (or reasons for visiting the clinic)*
- Routine Checkup
- Immunizations (shots)
- A health problem
- Switching doctors
Please specify the health problems*
Please name the child's previous doctor*
How do you feel your child acts or behaves?*
- Poor
- Fair
- Good
- Very Good
- Excellent
Has your child ever been a patient in a hospital?*
- Yes
- No
If yes, please explain why and when*
Is your child taking any prescription medicines?*
- Yes
- No - My child does not take any prescription medicines.
Can you bring the child's medicines?*
- Yes
- No
Please list the child's medications below
Name of Medicine Dosage
How many pills or doses does your child take at:*
Morning Noon Dinner Bedtime
What pharmacy do you use for your child?*
What over-the-counter medicines does your child take regularly?*
- Vitamins
- Herbal Medicine
- None
Please list the herbal medicines used*
Does your child have any allergic reaction (bad effect) from any of the following? (Check all that apply)*
- Outside or Indoor allergies (for example: grass, pollen, cats …)
- Food Allergies (for example: peanuts, milk, wheat …)
- Medicine or shots (immunization)
- No, my child has no allergies that I know of.
Please list any medicine or shots your child is allergic to*
Name of Medicine What happened when your child took the medicine?
Please list the previous Medical Providers your child has seen
Medical Problems
Please check any of the following medical problems that your child has ever had.*
- Ear Infections
- Nose Problems (sinus infections, nose bleeds)
- Eye problems (blurry vision, wears glasses)
- Hearing problems
- Mouth or throat problems (strep throat, swallowing problems)
- Diarrhea (having frequent and runny bowel movement)
- Constipation (problems having a bowel movement)
- Vomiting
- Problems urinating (bed wetting, pain when urinating)
- Back problems (crooked back, back pain)
- Growing pains (bone or body pains due to growing)
- Muscle and bone problems (weak muscles, pain in joints)
- Skin problems (acne, flaking skin, rashes, hives)
- Seizures
- ADD / ADHD (problems paying attention, sitting still)
- Sleeping problems (falling or staying asleep)
- Breathing problems (cough, asthma)
- Warts
- Jaundice (yellow skin)
Has your child received immunizations (shots) in the past?*
- Yes
- No
Does anyone in your household smoke?*
- Yes
- No
The following questions are about the mother of the child during pregnancy and birth.
Were any of the following used during pregnancy? (Check all that apply)*
- Cigarettes
- Alcohol
- Illegal Drugs
- Prescription Drugs
- None of the above
Please list which prescription drugs were used*
Please list which illegal drugs were used*
Did the mother have any of the following conditions or problems during pregnancy?
- Preeclampsia (high blood pressure)
- Diabetes (sugar)
- Emotional stress
- Injury or serious illness
- Unexpected bleeding or spotting
- Other
What other conditions do you encounter during your pregnancy?*
Was the pregnancy*
- On the due date
- Before the due date
- After the due date
by how much?*
Was the birth
- Vaginal
- C-Section
Were any of the following used?
- Pain medicine during birth (epidural)
- Tool to help pull baby out (forceps or vacuum)
- None
Were there any problems during the birth?*
- Yes
- No
If yes, please explain*
Was / is the child breastfed?*
- Yes
- No
If yes, how long*
In the first 2 months after birth, did the child have:
- Jaundice (yellow skin)
- Colic (upset stomach, crying)
- Breathing problems
- None of the above
At what age did the child:*
Begin to crawl Begin to sit up Get his/her first tooth Begin to say words (mama, dada)
How would you rate your child’s health in his or her first year of life?*
- Excellent
- Very Good
- Good
- Fair
- Poor
Daycare / School Information
Does the child go to daycare?*
- Yes
- No
If yes, what is the name of the daycare?*
If your child goes to school or daycare, describe how your child acts in school or daycare. (Check all that apply)*
- Select All
- Nervous, worried
- Hyper, restless, can't sit still
- Pushy, bullies others
- Relaxed, calm
- Social, friendly
- Shy, withdrawn, keeps to self
- Gets angry easily
- Scared, fearful
- Moody
- Happy
How are your child's grades in school?*
Health / Nutrition Information
About how much exercise does your child get every day?*
About how many hours of TV does your child watch every day?*
About how many hours is your child on a computer every day?*
About how many hours does your child spend outside every day?*
About how many hours are spent reading with your child every day?*
Does your child wear a helmet when riding a bike, roller blading, skateboarding, etc?*
- Yes
- No
Does your child get buckled in a car seat or wear a seat belt when riding in a car?*
- Yes
- No
Do you have guns in the home?*
- Yes
- No
If yes, are they safely locked up?*
- Yes
- No
Is your child old enough to be involved in activities?*
- Yes
- No
If yes, please list what activities your child is involved in*
Please list what your child typically eats and drinks in a day*
Please check all the people that the child lives with*
- Mother
- Father
- Brothers
- Sisters
- Other family members
- Friends or other people
- Animals
How many brothers?*
How many sisters?*
Please list the other family members*
Please list the friends or other people*
Please list the animals the child lives with*
Family Medical History
What medical problems do the parents of the child have?*
- Depression
- Anxiety (nerve) problems
- Learning disability
- Overweight
- High blood pressure
- Diabetes (sugar)
- Cancer
- Heart problems
- Other
Please list the other medical problems in the child's parents*
What medical problems do the siblings of the child have?
- Depression
- Anxiety (nerve) problems
- Learning disability
- Overweight
- High blood pressure
- Diabetes (sugar)
- Cancer
- Heart problems
- Other
Please list the other medical problems in the child's siblings*
Acknowledgements
WHEN YOU ARE SEEN BY AN EMPLOYEE OR CONTRACTOR OF THE CLINIC, YOU HAVE THE RESPONSIBILITY TO:
- Treat the staff with consideration, respect, and dignity.
- Understand that your life-style does affect your health.
- Take an active part in your health care.
- Follow the agreed-upon treatment plan. If you choose or are unable to follow the treatment plan, it is your responsibility to inform the Medical Provider.
- Observe facility rules and regulations that are for the safety and consideration of all patients and staff.
- Provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications, advance directives (living wills or durable power of attorney), and other matters relating to your healthcare.
- Report whether you understand a contemplated course of action and what is expected of you.
WHEN YOU ARE SEEN BY AN EMPLOYEE OR CONTRACTOR OF THE CLINIC, YOU HAVE THE RIGHT TO:
- Be treated with consideration, respect, and dignity;
- Have the confidentiality of your medical information protected, to have privacy act regulations enforced, and to have these areas of confidentiality explained to you in the language you can understand;
- Have privacy during case discussion, counseling & treatment;
- Review your records in the presence of a healthcare professional;
- Know the name and qualifications of staff providing your care;
- Know your diagnosis, health problems, test results, the potential advantages and risks of treatment or procedures in the language you can understand;
- Expect that all services, treatment and counseling techniques will take place with your informed consent;
- Participate in referral planning;
- Have access to the patient comment procedure;
- Refuse to participate in research.
- Have another individual present in the exam room with you, if you so desire.
Signature and Authorization
Today's Date*
MM slash DD slash YYYY
Consent for Photograph*
I consent to allow photography of above named patient for identification purposes, and for purposes of improving my medical care documentation (ie: wounds, lesions, etc)..
- I agree
Authorization for Treatment*
I hereby authorize, Minidoka Medical Center, and any assistants or associates that may be designated, to perform medical and hospital care to the above named patient.
- I agree
Privacy Practices / Discrimination*
I have received/or declined copy of the Notice of Privacy Practices for above named patient and I have been provided an opportunity to review this entire document. Minidoka Memorial Hospital and Medical Center will not discriminate against a patient because of race, color, national origin, religion, ability to pay, or because a patient is covered by a program such as Medicaid or Medicare. If you feel you are a victim of discrimination you have the right to file written compliant to the Compliance Officer. Forms are available in the business office.
- I agree
Consent to use of answering machine and / or voicemail messaging / email*
I hereby consent to the use of my answering machine and/or voicemail for the purpose of relaying important information regarding treatment or care, of above named patient, including, but no limited to confirmation of appointments, changes in medication, results of lab tests, special instructions for testing procedures. I also consent to members of my family receiving this information in my absence. This consent will remain in effect until I rescind the consent in writing.
- I agree
Patient Signature (or parent of minor)*
*
- I authorize release of any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor.
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Pediatric Registration Packet

Patient Information

In Case of Emergency

Insurance Information

Patient Info (Child)

Medical Problems

The following questions are about the mother of the child during pregnancy and birth.

Daycare / School Information

Health / Nutrition Information

Family Medical History

Acknowledgements

Signature and Authorization

LATEST NEWS

OUR ADDRESS

1224 8th Street
Rupert, Idaho
83350

(208) 436-0481

Notice of Privacy Practice
Aviso de Prácticas de Privacidad

LATEST NEWS

OUR ADDRESS

1224 8th Street
Rupert, Idaho
83350

(208) 434-8340

Notice of Privacy Practice
Aviso de Prácticas de Privacidad

OUR ADDRESS

1224 8th Street
Rupert, Idaho
83350

(208) 436-0481

Notice of Privacy Practice
Aviso de Prácticas de Privacidad

Name of parent / head of household	Parent / guarantor of Birth	Phone Number (if different)

Name of Medicine	What happened when your child took the medicine?

Child's Name	Child's Date of Birth	Current Age	Child's Gender

Morning	Noon	Dinner	Bedtime