Pediatric Registration Packet Patient InformationPatient Name*FirstMiddleLastAddress Where the Child Lives* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 householdParent / guarantor of BirthPhone Number (if different) Guarantor's Employer* Guarantor's Work PhoneIn Case of EmergencyEmergency contact information*Name of ContactPhone NumberRelationship to Patient Person who can call and receive patient medical information: (for confidentiality purposes)Name of ContactPhone NumberRelationship to Patient Insurance InformationWho 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 AmountDeductibleCo-PayDo 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 AmountDeductibleCo-PayPatient Info (Child)Child's InfoChild's NameChild's Date of BirthCurrent AgeChild'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 belowName of MedicineDosage How many pills or doses does your child take at:*MorningNoonDinnerBedtime 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 MedicineWhat happened when your child took the medicine? Please list the previous Medical Providers your child has seen Medical ProblemsPlease 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 crawlBegin to sit upGet his/her first toothBegin 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 InformationDoes 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?*Pick oneExcellentOkayPoorDoes not attend schoolHealth / Nutrition InformationAbout how much exercise does your child get every day?*Pick oneLess than 30 minutes30 minutes to 1 hourOver 1 hourAbout how many hours of TV does your child watch every day?*Pick oneLess than 1 hour1-3 hoursMore than 3 hoursAbout how many hours is your child on a computer every day?*Pick oneLess than 1 hour1-3 hoursMore than 3 hoursAbout how many hours does your child spend outside every day?*Pick oneLess than 1 hour1-3 hoursMore than 3 hoursAbout how many hours are spent reading with your child every day?*Pick oneLess than 15 minutes15-30 minutes30 minutes to 1 hourMore than 1 hourDoes 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 HistoryWhat 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*AcknowledgementsWHEN 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 AuthorizationToday'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)* Reset signature Signature locked. Reset to sign again * 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. CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ
