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6440 W. Newberry Road, Suite 402, Gainesville, FL 32605 - Phone:
(352) 333-5500
- Fax: (352) 333-5506
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New Patient Form
gnvpa
2023-01-16T01:19:53-05:00
Date
MM slash DD slash YYYY
Form Completed by
First Name
Last Name
Email
Patient Name
Ethnicity
Sex
Male
Female
Date of Birth
MM slash DD slash YYYY
Informant
(parent/guardian)
How did you hear about us?
Child's Medical History
Child's Previous Doctor?
Has your child ever had ...
Allergies?
Yes
No
Please List
List of Allergies
Asthma/Wheezing
Yes
No
Asthma Action Plan
Pneumonia
Yes
No
Chicken Pox
Yes
No
Year
Frequent Ear Infections
Yes
No
Vision Problems
Yes
No
Hearing Problems
Yes
No
Skin Problems/Eczema/Hives
Yes
No
Seasonal Allergies
Yes
No
Seizures / Epilepsy
Yes
No
High Blood Pressure
Yes
No
Heart Defects / Disease
Yes
No
Liver Disease
Yes
No
Diabetes
Yes
No
Kidney Disease
Yes
No
Bladder Infections
Yes
No
Physical or Learning Disabilities
Yes
No
Bleeding Disorders/Hemophilia
Yes
No
Sexually Transmitted Infections
Yes
No
Emotional/Behavior Problems
Yes
No
Depression/Suicidal Thoughts
Yes
No
Hospitalizations/Surgeries
Yes
No
Physical/Sexual/Emotional Abuse
Yes
No
Bone or Joint Injuries
Yes
No
Dental Problems
Yes
No
Obesity/Overweight
Yes
No
Eating Disorders
Yes
No
Sleep Problems
Yes
No
Attention Deficit Disorder
Yes
No
Lead Poisoning
Yes
No
Vaccines Up-To-Date
Yes
No
Other Concerns
Current Medications
Family Medical History
Has any parent(P), grandparent(GP), aunt(A), uncle(U), sister(S) or brother(B) had...
Severe Food Allergies
Yes
No
Who?
Asthma/Wheezing
Yes
No
Who?
TB/Lung Disease
Yes
No
Who?
Cystic Fibrosis
Yes
No
Who?
Genetic Disorders
Yes
No
Who?
Migraines
Yes
No
Who?
Heart Disease
Yes
No
Who?
Sudden Cardiac Death
Yes
No
Who?
High Blood Pressure
Yes
No
Who?
Stroke
Yes
No
Who?
High Cholesterol
Yes
No
Who?
Blood Disorders
Yes
No
Who?
Sickle Cell
Yes
No
Who?
Anemia
Yes
No
Who?
Thalassemia
Yes
No
Who?
Clotting Disorders
Yes
No
Who?
Diabetes
Yes
No
Who?
Seizures
Yes
No
Who?
Mental Illness
Yes
No
Who?
Depression
Yes
No
Who?
Suicide Attempts
Yes
No
Who?
Cancer
Yes
No
Who?
Breast Cancer
Yes
No
Who?
Cervical Cancer
Yes
No
Who?
Colorectal Cancer
Yes
No
Who?
Other type of Cancer
Yes
No
Who and What Type?
Birth Defects
Yes
No
Who?
Hearing Loss
Yes
No
Who?
Speech Problems
Yes
No
Who?
Kidney Disease
Yes
No
Who?
Alcohol/Drug Abuse
Yes
No
Who?
Hepatitis/Liver Disease
Yes
No
Who?
Irritable Bowel Syndrome
Yes
No
Who?
Thyroid Disease
Yes
No
Who?
Crohn Disease
Yes
No
Who?
Ulcerative Colitis
Yes
No
Who?
Attention Deficit Disorder
Yes
No
Who?
Mental Retardation
Yes
No
Who?
Family Violence
Yes
No
Who?
Other Concerns
Has any family member ever had an unexplained, unexpected death before age 50?
Yes
No
if yes, please describe
Pregnancy and Birth History
Adopted
Yes
No
Prenatal Care
Yes
No
Illnesses during pregnancy:
Yes
No
Please Describe
Medications during pregnancy
Yes
No
Please List
Alcohol/Drug Abuse
Yes
No
Tobacco use
Yes
No
Problems at birth
Yes
No
Mom: Miscarriage
Yes
No
Baby
Please select all that apply
Jaundice
Heart Murmur
Infection
Breathing Problems
Birth Defects
Other
If other, please describe the problems at birth
Name of Hospital
Week of gestation when child was born
Type of Delivery
Vaginal
C-Section
VBAC
Birth Weight
Discharge Weight
Newborn Hearing Screening
Yes
No
Did baby receive Hep B vaccine?
Yes
No
Date of Hep B vaccine?
Psychosocial History
Who lives in household:
Pets
Water Source
Who cares for child
Is child in daycare
Yes
No
If in school, what grade?
Kinds of exercise/sports?
TV use per day?
Parent 1 Name
Date of Birth
MM slash DD slash YYYY
Occupation
Parent 2 Name
Date of Birth
MM slash DD slash YYYY
Occupation
Are parents divorced or separated
Yes
No
Tobacco use in household
Yes
No
Sleep Problems
Yes
No
Other Languages
Medication Allergies (Please List)
Severe Food Allergies (Please List)
Feeding & Digestion
Breast fed
Yes
No
Formula
Severe colic in first 3 months
Yes
No
Feeding problems
Yes
No
Good appetite
Yes
No
Vitamins or other supplement
Yes
No
Eats balanced diet
Yes
No
Constipation problems
Yes
No
Food allergies/issues
Yes
No
Medical History
Broken Bones
Yes
No
Serious accidents
Yes
No
Surgeries
Yes
No
Hospitalizations
Yes
No
ER visits / Urgent Care
Yes
No
Please Explain
Additional Information
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