PATIENT REGISTRATION Patient Information · 2019-09-26 · allergies/medicines hospitalizations/surgery/ injuries Please list any medicines your child is currently taking Please list

1/2/19 ksw

Address: __________________________________________________________________________

Home phone: ______________________ Cell phone: ____________________

PATIENT REGISTRATION Patient Information

Name: ______________________________________________________________________________________ First Middle Last

Address: ____________________________________________________________________________________

Social Security Number: ____________________Home phone: (____)_____________ Cell Phone: (____)____________

Date of Birth: ______________ Marital Status: ________ Gender: ⃝ M ⃝ F

Race: ⃝ American Indian/Alaska Native ⃝ Asian ⃝ Black ⃝ White ⃝ Native Hawaiian ⃝ Other Pacific Islander

Ethnicity: ⃝ Hispanic or Latino ⃝ Not Hispanic or Latino

Do you have medical insurance? ⃝ Yes ⃝ No

If you do not have insurance, would you like to get information about our reduced fee program? ⃝ Yes ⃝ No

Are you a US veteran? ⃝ Yes ⃝ No Are you homeless? ⃝ Yes ⃝ No

Parent’s Information (Complete this section for a patient less than 18 years old)

Emergency Contact Personntact Person:

Name:____________________________________________________________/________________ First Middle Last Relationship to patient

_______________________________________________________________/________________ Address Phone

Person Responsible for Payment (Complete this section for a patient less than 18 years old)

Name:__________________________________________________________/________________ First Middle Last Relationship to patient

Social Security Number: ___________________________ Date of Birth: ___________________________ I agree that the above information is correct and accurate to the best of my knowledge. I also understand that any charge(s) not covered by my insurance(s) will be my responsibility.

Signature: _________________________________________ Date: ________________________

For Office Use Chart #: Insurance scanned: yes/no Date: Initials:

Mother’s Name: _____________________________________________________ Date of Birth:_______/________/______ First Middle Last

Father’s Name: _____________________________________________________ Date of Birth:_______/_______/_______ First Middle Last

Is there a Legal Child Custody Agreement? ⃝ Yes ⃝ No (If yes, are there any legal restrictions that would prevent the non-custodial parent from consenting to medical/dental treatment for the child or from obtaining information about the child’s medical/dental treatment?) ⃝ Yes ⃝ No

***Please provide proof of parental custody orders or other legal agreements***

PERMISSION TO SHARE PROTECTED

HEALTH INFORMATION

Patient’s Full Name: _________________________________________________________________ (First) (Middle) (Last)

Patient’s Date of Birth: ________/___________/__________Telephone:_______________________

Keystone Health shares one electronic record. Any person(s) you authorize will have access to your financial/medical/dental and behavioral health information.

Name: __________________________________Relationship to Patient: ______________________ Name: __________________________________Relationship to Patient: ______________________ Name: __________________________________Relationship to Patient: ______________________ Keystone Health uses a reminder system and/or patient portal to communicate with our patients. Please complete the information below, so that we may keep in touch with you regarding your health.

Cell Phone:________________________________________________(you will receive a text message) E-mail:_____________________________________________________ (you will receive an email) By signing, I give permission to Keystone Health to share my protected health information to the individuals listed. This permission remains in effect until revoked in writing. _________________________________________ __________________________ Signature of Patient or Authorized Representative Date (Patients 14 years and older must sign if consenting for treatment on own behalf)

________________ Staff Initials 2/14/19 ksw

KEYSTONE HEALTH Ages 0 – 6 years

PEDIATRIC HEALTH HISTORY QUESTIONAIRE

Child’s Name: ___________________________ Age: _________ Sex: M or F Date of Birth: _________ (circle)

PREGNANCY AND BIRTH Please complete this section if your child is under age 2 years

Please circle any problems during pregnancy: Was this pregnancy planned? --------------------YES NO Bleeding Swelling High Blood Pressure Did the mother smoke during pregnancy----- YES NO Kidney infection Diabetes Vaginal Infection Did the mother drink alcohol during Other _________ pregnancy?--------------------------------------YES NO

(beer, wine or mixed drinks) Who delivered: _____________________ Did the mother take any medications during

pregnancy? ------------------------------------------ YES NO Where: _____________ (Please list: _________________________) Birthweight: ____lbs ___oz. Did the mother take any other drugs during

pregnancy?------------------------------------------- YES NO (Please list: _________________________)

Was birth ___on time ____late ____early? Was delivery ____vaginal ____C-section? Please circle any problems your baby had in the Did mother have any problems during or after hospital:

labor and delivery? YES NO Yellow jaundice Turned blue Seizures Vomiting Was infant: ____breastfed ____ bottlefed Infection Constipation Breathing tube

Other: _____

FAMILY HISTORY Please complete this section for any age child

Mother’s Name: __________________________ Date of Birth: ______________ Living at home: YES NO Mother’s health: __________________________ Occupation: _______________ Father’s name: ____________________________ Date of Birth: ______________ Living at home: YES NO Father’s health: ____________________________ Occupation: _______________ Brothers and sisters:

Names Birthdates Health Problems

Please circle any of these diseases that your child’s grandparents, parents, aunts, uncles, brothers, or sisters have or have had:

Asthma Hay fever Eczema Tuberculosis Kidney trouble Depression High cholesterol Diabetes Seizures Stroke Heart attack Hearing loss SIDS Heart murmur Alcoholism Cancer Drug addiction HIV Sickle Cell Other: ______________

1


PEDIATRIC HEALTH HISTORY QUESTIONAIRE

PAST ILLNESSES

Please circle any illnesses or problems that your child has had Asthma Hay Fever Eczema Kidney Trouble Heart Murmur Speech problems Seizures Hearing Loss Chicken pox Pneumonia Frequent headaches Bedwetting Hyperactivity Constipation Kidney or bladder infection Frequent ear infection List others: _____________________________________________________________________________ ALLERGIES/MEDICINES HOSPITALIZATIONS/SURGERY/ INJURIES Please list any medicines your child is currently taking Please list the date & reasons if your child & allergies that your child currently has and write has ever had any hospitalizations, surgeries, down the reactions: &/or injuries: Medicines currently taking: __________________________________________ Date Reason __________________________________________ __________ ______________ __________________________________________ __________ ______________ __________________________________________ __________ ______________ __________ ______________ ALLERGIES: __________ ______________ __________________________________________ __________________________________________ __________________________________________ SAFETY: NUTRITION Please answer for any age child Please answer for any age child Does anyone smoke at home? YES NO Does your child have any eating Do you have a smoke detector at home? YES NO problems? YES NO Do you have any guns in your home? YES NO Please answer if your child is over age 1 If your child is under age 5, do you have ipecac syrup & the Poison Control phone # Do you limit sweets, fats & junk food? YES NO posted in your home? YES NO Does your child eat foods from each of the IIs your hot water heater turned down to 4 food groups (fruits/vegetables, breads/ 120? YES NO cereals, dairy products, meats) daily? YES NO If your child rides a bicle, does he/she Does your child skip meals? YES NO wear a helmet? YES NO Does your child eat paint chips or chew on Do you know how to do the Heimlich window sills? YES NO maneuver for children? YES NO Is your child in the WIC Program? YES NO Do you use a #15 (or higher) sunscreen on your child? YES NO BEHAVIOR Please answer if child is age 1 year or older by DENTAL checking any behavior problems that your child Please answer for any age child has: ____Temper tantrums ____Steals Do you have well water in your home? YES NO ____Whines ____Lies Does your child brush his/her teeth daily? YES NO ____Cries easily ____Hyperactive Does your child see a dentist regularly? YES NO ____Hits or bites ____Short attention ____Shyness ____Disobedient

2


PEDIATRIC HEALTH HISTORY QUESTIONAIRE SCHOOL HABITS Please answer if your child has started school Please answer if your child is 1 year or older Has your child failed any grades? YES NO Does your child watch more than 1 or 2 hours of Has your child had any learning problems? YES NO TV daily? YES NO Has your child been absent from school Does your child always use a car seat or seat more than 10 days a year? YES NO belt? YES NO Does your child exercise daily? YES NO Does your child have a regular bedtime? YES NO SOCIAL Please check if any of these concerns are troubling your family: ____hospital bills ____housing/rent ____occupation ____emotional problems/nerves ____transportation ____community agencies ____legal ____other money matters ____marriage ____other stresses___________ WHO COMPLETED THIS FORM: ____________________________________________ RELATIONSHIP TO CHILD: ______________________________________ CHILD’S NAME: ___________________________________________ DATE COMPLETED: ________________________________ DO NOT WRITE BELOW THIS LINE- FOR OFFICE USE ONLY!

Family History (There are two methods of recording the family history. The diagram- matic format is more helpful than the narrative in tracing genetic disorders. The negative family information follows either format.)

Train accident Stroke, varicose veins, headaches 43 57 Infancy High 61 58 54 Blood Heart Attack Pressure Migraine headaches 33 31 27

Indicates patient Deceased male Deceased female Living male Living female

Outline: Father died, 43, train accident Mother died, 67, stroke, had varicose veins, headaches One brother, 61, has high blood pressure, otherwise well One brother, 58, apparently well but for mild arthritis One sister, died in infancy, ?cause Husband, died, 54, heart attack One daughter, age 33, “migraine headaches”, otherwise well One son, 31, headaches One son, 27, well

3 KEYSTONE HEALTH

BLOOD LEAD RISK ASSESSMENT

INSTRUCTIONS: Please answer the following questions.

1. Does your child live in or regularly visit a building with peeling or chipping paint YES NO built before 1978? (This could include a day care center, preschool, home of a baby sitter or relative)

2. Does your child live in or regularly visit a building built before 1978 with recent, YES NO ongoing, or planned remodeling or renovations?

3. Has your child, housemate or playmate been treated or followed for lead YES NO poisoning (lead level 15 or more?)

4. Does your child live with an adult whose job or hobby involves exposure to YES NO lead (furniture refinishing, making stained glass, indoor firing range, or pottery making)?

5. Does your child live near an active lead smelter, battery recycling plant or YES NO other industry likely to release lead?

6. Do you use home remedies from other cultures such as “non-Western” YES NO medicines and cosmetics? NURSING STAFF Review questionnaire with client’s parent/guardian at subsequent well child exams: 9 mos. __________ 12 mos. __________ 15 mos. __________ 18 mos. __________ 24 mos. __________ 3 yrs. __________ 4 yrs. __________ 5 yrs. __________ 6 yrs. __________

PEDS RESPONSE FORM

Provider: ___________________ Child’s Name: _______________________ Parent’s Name: ____________________________________ Child’s Birthday: _____________________ Child’s Age: ____________ Today’s Date: _______________ Please list any concerns about your child’s learning, development, and behavior. Do you have any concerns about how your child talks and makes speech sounds? Circle one: No Yes A little COMMENTS: Do you have any concerns about how your child understands what you say? Circle one: No Yes A little COMMENTS: Do you have any concerns about how your child uses his or her hands and fingers to do things? Circle one: No Yes A little COMMENTS: Do you have any concerns about how your child uses his or her arms and legs? Circle one: No Yes A little COMMENTS: Do you have any concerns about how your child behaves? Circle one: No Yes A little COMMENTS: Do you have any concerns about how your child gets along with others? Circle one: No Yes A little COMMENTS: Do you have any concerns about how your child is learning to do things for himself/herself? Circle one: No Yes A little COMMENTS: Do you have any concerns about how your child is learning preschool or school skills? Circle one: No Yes A little COMMENTS: Please list any other concerns: (12/13/13)

PERMISSION FOR TREATMENT OF CHILDREN

Patient’s Full Name: ________________________________________________________________ (First) (Middle) (Last)

Patient’s Date of Birth: ______/________/___________ Name of Parent/Legal Guardian: ______________________________________________________ If I can’t bring my child to a medical/behavioral health or dental appointment, I give permission for the person(s) listed below to go with my child to visits at Keystone Health Center. He/she can also approve treatment for my child during the visit, including shots and minor dental and medical procedures. Name: ___________________________________Relationship to Patient: ______________________ Name: ___________________________________Relationship to Patient: ______________________ Name: ___________________________________Relationship to Patient: ______________________ Please Note: Sometimes, the provider may decide that a parent must be present for certain dental procedures: extractions, root canals, surgical procedures, nitrous visits and operating room visits. This permission remains in effect until revoked in writing. _____________________________________ _____________________________ Parent/Guardian Signature Date _______________________________________ _____________________________ Witness Signature Date _____________ Staff Initials 2./14/19 ksw

As a Community Health Center, our mission is to take care of people no matter what their race, ethnicity or

income. This survey will help us know if we are helping all kinds of families within our community. Please fill in the information below to best tell us about you and your family.

Race- relates to a persons appearance such as skin color:

□ White/Caucasian □ Black/African American □ Asian □ American Indian

□ Native Hawaiian □ Other Pacific Islander □ Multi-racial

Ethnicity- relates to nationality and culture: □ Latino/Hispanic □ Non Latino

Do you live in public housing:

□ Yes □ No

Family Size Annual Family Income

1 $12,490 and below $12,491 to $18,735 $18,736 to $24,980 $24,981 and above










Revised 3.13.19

Keystone Vaccine Policy Statement

We firmly believe in the effectiveness of vaccines to prevent serious

illness and to save lives.

We firmly believe in the safety of our vaccines.

We firmly believe that all children and young adults should receive all

of the recommended vaccines according to the schedule published by

the Centers for Disease Control and Prevention and the American

Academy of Pediatrics.

We firmly believe, based on all available literature, evidence, and

current studies, that vaccines do not cause autism or other

developmental disabilities. We firmly believe that thimerosal, a

preservative that has been in vaccines for decades and remains in

some forms of the influenza vaccine, does not cause autism or other

developmental disabilities.

We firmly believe that vaccinating children and young adults may be

the single most important health-promoting intervention we perform

as health-care providers, and that you can perform as

parents/caregivers. The recommended vaccines and their schedule

given are the results of years and years of scientific study and data

gathering on millions of children by thousands of our brightest

scientists and physicians. Trusted information can be obtained here:

http://vec.chop.edu/service/vaccine-education-center/home.html

http://vec.chop.edu/service/vaccine-education-center/home.html

Updated 8/2018

Keystone Health Vaccine Schedule

Birth 2mo 4mo 6mo 12mo 15mo 18mo 4-6yr 10yr 11yr 16-18yr

Hep B X

Pediarix X X X

Prevnar X X X X

Rotavirus X X

Dtap X

Hib X X X

Kinrix X

Hep A X X

MMR X

Varicella X

Meningococcal X X

Tdap X

HPV

*for boys and

girls*

X

(Ages

9-26)

X X

(will only need 3rd

dose if started

after age 15)

MMR-V X

Men B X

Pediarix- Dtap, IPV, and Hep B Kinrix- Dtap and IPV MMR-V- MMR and Varicella

Documents

PATIENT REGISTRATION Patient Information · 2019-09-26 · allergies/medicines hospitalizations/surgery/ injuries Please list any medicines your child is currently taking Please list