post_New_Patient

Patient Name

Appointment Date

Date

Patient’s date of birth

Date

Mother’s Name:

Can this person drop off/pick up your child?

Father’s Name:

Can this person drop off/pick up your child?

Diagnosis (if any)

Who referred you to Kindred Pediatrics?

Address

Home Address

Street Address Line 2

CityState

Zip Code

Cell Phone

Format: (000) 000-0000.

Work Phone

Format: (000) 000-0000.

Email

example@example.com

Emergency Contact 1:

Relation

Phone

Format: (000) 000-0000.

Can this person drop off/pick up your child?

Emergency Contact 2

Relation

Phone

Format: (000) 000-0000.

Can this person drop off/pick up your child?

Please list everyone who lives in the patient’s home: (Name/relation/age)

1

2

3

4

5

6

7

8

Primary Care Physician

Phone

Format: (000) 000-0000.

Fax

Please enter a valid phone number.Format: (000) 000-0000.

INSURANCE INFORMATION *Attach copy of front & back of patient's insurance card(s) Please indicate if patient is covered under Primary and/or Secondary insurance coverage

Primary Plan

Insured Name

Policy or ID #

Relationship to insured

Group #

Insured date of birth

Date

Secondary Plan

Secondary Insured Name

Policy or ID #

Relationship to insured

Group

Insured date of birth

Date

Weeks of Gestation

Due Date

Date

Birth Weight

Delivering Hospital

Medications taken during pregnancy

Other exposures during pregnancy

Birth History Unknown

Complications with pregnancy, delivery, birth

Please describe feeding at birth

0/140

Extended Hospitalization?

Length of stay

Reason for extended hospitalization

PostNatal Complications

Oxygen

Length of Time

Feeding Tube

Length of Time

NICU

Length of Time

IVH

Grade

Special Precautions

Allergy Alert

0/100

Other or comments

Crawled

Walked

Finger fed self

Babbled

Dressed Self

Rolled from stomach to back

Fed self with utensils

Sat un-supported

Used two-wordcombinations

Used Sentences

Said First Word

Slept all night

Toilet trained

Pulled to stand

Drank from cup

Has your child’s hearing been tested?

Date Tested

Date

Results

Comments

Has your child been hospitalized?

Has your child had any surgeries?

If yes, please provide the following information:

1. Date

Date

Age

Hospital

Reason

2. Date

Date

Age

Hospital

Reason

3. Date

Date

Age

Hospital

Reason

4. Date

Date

Age

Hospital

Reason

5. Date

Date

Age

Hospital

Reason

Does your child take medication?

(Please list ALL medications your child is currently taking.)

1. Medication

Purpose

Dosage

Prescribing Doctor

2. Medication

Purpose

Dosage

Prescribing Doctor

3. Medication

Purpose

Dosage

Prescribing Doctor

4. Medication

Purpose

Dosage

Prescribing Doctor

Speech: Begin Date

Date

End Date

Date

Location/Doctor/Therapist:

Occupational: Begin Date

Date

End Date

Date

Location/Doctor/Therapist:

Physical: Begin Date

Date

End Date

Date

Location/Doctor/Therapist:

Behavioral/Counseling: Begin Date

Date

End Date

Date

Location/Doctor/Therapist:

Cardiologist: Begin Date

Date

End Date

Date

Location/Doctor/Therapist:

Audiologist: Begin Date

Date

End Date

Date

Location/Doctor/Therapist:

Neurologist: Begin Date

Date

End Date

Date

Location/Doctor/Therapist:

Gastroenterologist: Begin Date

Date

End Date

Date

Location/Doctor/Therapist:

Other: Begin Date

Date

End Date

Date

Location/Doctor/Therapist:

Does your child attend school?

If yes, where do they attend?

What type of classroom are they in?

Ratio

What is their teachers name?

If no, where does your child stay during the day?

Other

What are your primary concerns regarding your child?

When did you first notice the reason for your concerns?

How does your child express his/her needs (i.e. ask, point, cry, scream, one word, pull, caregiver toward area, etc.)?

Did your childs doctor express concern? If so please explain

What are your child's strengths?

What are your child's weaknesses?

What are your child's favorite activities (i.e. toys, games, food, etc.)?

What are your goals for therapy?

Is there anything that seems unusually difficult for your child or your family?

Is there a day of the week and/or time that you prefer for appointments if your child qualifies for therapy?

Kindred Pediatric Therapy New Patient Intake Form

Personal Information

MEDICAL INFORMATION - PHYSICIAN

BIRTH HISTORY

PATIENT MEDICAL HISTORY

FAMILY/SOCIAL HISTORY

MILESTONES

AUDIOLOGY

SURGERIES & HOSPITALIZATIONS

SURGERIES & HOSPITALIZATIONS

TREATMENT HISTORY

EDUCATIONAL HISTORY

PARENT/CAREGIVER FEEDBACK & CONCERNS