Laramie Pediatrics, pc
Welcome to the online office of Laramie Pediatrics, pc
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Laramie Pediatrics, pc
Welcome to the online office of Laramie Pediatrics, pc
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NEW PATIENT INFORMATION You may download this sheet and fill it out prior to your office visit to Laramie Pediatrics, pc. That will allow you to have most of the paperwork already filled out. Please fill this sheet
out as completely as you can so we have accurate information about our patients. If you
are unsure about any of the information asked for, please ask our receptionist or Patient
Accountant for help.
Patient’s
Name:___________________________M/F______Birthdate:__________Today’s date:___________
Address:_____________________________City:______________State:______Zip:________Phone:_________
Father’s
Name:______________________________ Mother’s
Name:_________________________________
Birthdate :
_________________________________ Birthdate
: ___________________________________
Place of
Employment:_________________________ Place of Employment:____________________________
Father’s Daytime
Phone:_______________________Mother’s Daytime Phone:_________________________
Father’s Social Security
#______________________Mother’s Social Security #_________________________
Health
Insurance:_____________________________Policy Numbers:_________________________________
Previous
Physician:___________________________Address:________________________________________
Relative or Friend to contact in
emergency:_______________________________________________________
Phone Number in case of
emergency:____________________Relationship____________________________
How did you find our office? Referred by:__________________Phone
Book___________Other__________
NAME
BIRTHDATE
HEALTH PROBLEM
Sibling__________________________
_______________ _________________________________________
Sibling__________________________
_______________ _________________________________________
MEDICAL HISTORY:
Patient’s delivery (circle): vaginal
C-section
Was the patient: early on time late
Newborn Problems: Jaundice
Breathing Problems other:____________________________________
Birth Weight:_________________ Breast fed or Formula:_________________Feeding
Problems_________
List any and/all medications the
patient is currently taking : __________________________________________
HAS THE PATIENT EVER HAD ANY OF THE
FOLLOWING? Medication allergy yes [ ] no [ ] list medication___________________ Food Allergy yes [ ] no [ ]
Hospitalization yes [ ] no [ ] if
“yes” state when ___________________________________________
Asthma
yes
[ ] no [ ]
Allergies or Hay Fever yes [ ] no [ ]
Tonsillitis
yes
[ ] no [ ]
Diabetes
yes [ ] no [ ] Heart Problems
yes [
] no
[ ] Ear Infections
yes [ ] no [ ]
Ulcers
yes [ ] no [ ]
Urinary Tract Problems yes [ ] no [ ] Meningitis yes [ ] no [ ]
Depression yes [ ] no [ ] Hearing Problems
yes [ ] no [ ] Vision
Problems yes [
] no [ ]
Emotion or Behavior Problems yes [ ] no [ ]
Developmental Delays yes [ ] no [ ]
Explain any “yes” answers
____________________________________________________________________
DOES ANYONE IN THE FAMILY HAVE:
(please include mothers, fathers,
siblings, grandparents, aunts and uncles)
Diabetes
yes [
] no
[ ]
Rheumatoid Arthritis
yes [
] no
[ ]
Seizures
yes [
] no
[ ]
High Blood Pressure
yes [
] no
[ ]
Cystic Fibrosis
yes [ ] no [ ]
Nerve or Muscular Diseases
yes [ ] no [ ]
Heart Problems
yes [
] no
[ ]
Urinary Tract Problems
yes [
] no
[ ]
Depression
yes [ ] no [ ]
Emotional Problems
yes [
] no
[ ]
Down’s Syndrome
yes [
] no
[ ]
Genetic Disorders
yes [
] no
[ ]
Hyperactivity
yes [
] no
[ ]
SIDS/Newborn Deaths
yes [
] no
[ ]
Explain any “yes” answers
____________________________________________________________________ I have completed this form entirely and
certify that I am the patient or duly authorized agent of the patient authorized to
furnish the information requested. I understand that even though I have some type of
insurance coverage, I am responsible for payment of the service and any interest applied
to the unpaid balance. I also authorize the release of any medical information necessary
to process any insurance claim. Signature:_________________________________________ Interest charges are 1.5 % monthly (or 18% per
year) on unpaid balances after 90 days. E-MAIL ADDRESS _____________________________ |
Send mail to
Klep@Laramiekids.com with
questions or comments about this web site.
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