di tric Jacksonville Kids AUTHORIZATION FOR TREATMENT Date: Date of Birth: Patient Name: Date of Birth: Patient Name: Date of Birth: Patient Name:
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5 Jacksonville Kids di tric AUTHORIZATION FOR TREATMENT Date: Patient Name: Patient Name: Patient Name: Patient Name: Patient Name: Patient Name: Date of Birth: Date of Birth: Date of Birth: Date of Birth: Date of Birth: Date of Birth: In the event that I am unable to bring my child(ren) to the office, I consent for the following persons to authorize medical care that is recommended by any of the Jacksonville Kids Pediatrics physicians. Name: Name: Relationship: Relationship: Name: Relationship: Parent/Guardian Signature:
6 Patient Name Medical History Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment. Medical History Check all diseases and conditions that apply. DADDorADHD o Developmental or Behavioral Disorders o Allergies o Diabetes o Anemia o Ear or Hearing Problems o Asthma o Eczema, Hives or other skin conditions o Bedwetting o Heart Problems o Bladder or Kidney Problems o Hospital Admission other than birth o Blood Diseases o Muscle, Joint, or Bone Problems o Breathing Problems o Reflux/GI o Cancer o Seizures/Epilepsy o Chicken Pox o Serious Illness or Injuries o Congenital Anomalies o Skin Problems o Constipation o Thyroid Problems o Depression o Vision or Eye Problems
7 Patient Name Surgical History Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment. Surgical History Check all surgeries that apply. o Adenoid Surgery o Myringotomy Tube Placement o Appendectomy o Neurosurgery o Cardiac Surgery o Nissen Fundoplication o Circumcision o Orthopaedic Surgery o Cleft Palate/Lip Repair o Other o Frenulectomy DPETubes o Gastric Surgery o Gastrostomy Tube Placement o Pyloric Stenosis Repair o Strabismus Surgery o Hernia Repair o Tonsillectomy o Hydrocele Repair o Tracheostomy o Hypospadias Repair DVP Shunt Placement
8 Patient Name Medication History Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment. Medication History List all current medications. Include prescribed and over-the-counter drugs, such as vitamins and inhalers. Medication Dosage Frequency Drug/Food Allergies Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment. Allergies List all known allergies. Allergy Reaction(s) Date of First Reaction (approx.)
9 Patient Name Family History Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment. Family History Check all diseases and conditions that apply. o Allergy o Anemia o Anxiety disorder Familymember(s): o Arthritis Family member(s): o Asthma o Blood coagulation disorder o Depressive disorder o Developmental disorder Family member(s):. Familymember(s): o Diabetes mellitus o Disease of liver o Disorder of thyroid gland Family member(s): o Family history of alcoholism Familymember(s): o Heart disease o Hypercholesterolemia Family member(s): o Hypertensive disorder o Immunodeficiency disorder Family member(s): o Kidney disease
10 o Malignant neoplastic disease Familymember(s): o Mental disorder Family member(s): o Migraine Family member(s):.._"" "."... " o Seizure disorder Family member(s): " o Substance abuse Family member(s): o Tuberculosis Family member(s):
11 Patient Name Social History Please review this form to ensure that your health information is accurate. You will be able to discuss any questions or concerns that you have with your provider during your appointment. Social History 1. Diet (Circle one) Regular Vegetarian Vegan Gluten free Specific Carbohydrate Cardiac Diabetic 2. Caffeine intake (Circle one) None Occasional Moderate Heavy 3. Exercise level (Circle one) None Occasional Moderate Heavy 4. Sporting activities 5. Parents' marital status (Circle one) Married Unmarried Separated Divorced Widowed 6. Home situation (Circle one) Both parents Mother Father Relatives Adoptive parents Foster parents Other 7. Siblings 8. Childcare? (Circle one) None Relative Private sitter Daycare/preschool 9. Animal exposure? (Circle one) Yes No 10. Passive smoke exposure? (Circle one)
12 Yes No 11. Smoke/CO detectors in home? (Circle one) Yes No 12. Seat belt/car seat used routinely? (Circle one) Yes No 13. Sunscreen used routinely (Circle one) Yes No 14. Insect repellent used routinely? (Circle one) Yes No 15. Year in school (Circle one) Pre-K Kindergarten HS Grad College 16. School name 17. Smoking Status (Circle one) Never smoker Former smoker Current every day smoker Current some day smoker Smoker - current status unknown Unknown if ever smoked
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15 Vaccination/Well Visit Schedule 3-5 day Newborn Well visit: No vaccines due unless Hep B#1 (Hepatitis B vaccine) not given at birth 2 week: No vaccines due 1 month: Hep 8#2 (assuming Hep B#l was given at birth hospital) 2 months: Pentacel #1 (DTap/IPV/HIB) which is the Diptheria/Tetanus/Pertussis (Whooping Cough)/Polio and HIB vaccine combo; Prevnar #1 (strep pneumo vaccine), Rotateq #1 (rotavirus oral vaccine) 4 months: Pentacel #2 (DTap/IPV /HIB), Prevnar #2, Rotateq #2 6 months: Pentacel #3 (DTap/IPV/HIB), Prevnar #3, Rotateq #3 9 months: Hep B #3, Hemoglobin (anemia check) 12 months: MMR# 1 (measles/mumps/rubella vaccine), Varicella #1 (chicken pox vaccine), Hep A #1 (Hepatitis A vaccine) 15 months: Prevnar #4, HIB #4, Hemoglobin check 18 months: Dtap #4, Hep A#2 2-3 years: No vaccines due unless needs to IIcatch up" 4 years: Quadracel (Dtap #5, IPV #4), Proquad (MMR#2/VZV#2), Hemoglobin check 5 years: No vaccines due 6 years-10 years: No vaccines due, yearly well visit recommended 11 years: Tdap (Tetanus booster with Pertussis booster vaccine), Menactra (meningococcal meningitis vaccine) 12 years: Gardasil (Human Papilloma Virus Vaccine) is a 2 or 3-series vaccine recommended now for both females and males years: Yearly well visit recommended, no vaccines due unless needs to IIcatch up" or start Gardasil series 16 years: Menactra # years: Yearly well visit recommended **We recommend every child 6 months and older receive a yearly flu vaccine**
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