New Child Patient Form (Page 3 of 3) in pdf

Has your child ever taken any of the group of drugs collectively referred to as “fen-phen?” These

include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin

 Y

 N

(fenfluramine) and Redux (dexfenfluramine)?

Has your child had any serious illnesses or operations? If yes, describe:

____________________________________________________________________________

Has your child ever had a blood transfusion?  Y  N

If yes, give approximate dates: _____________________________________________

Is your child pregnant?  Y  N

Nursing?  Y  N

Taking birth control pills?  Y  N

Check if your child has or has ever had any of the following:



Anemia

Cortisone Treatments

Hepatitis

Scarlet Fever



Arthritis, Rheumatism

Cough, Persistent

High Blood Pressure

Shortness of Breath



Artificial Heart Valves

Coughing Blood

HIV/AIDS

Skin Rash



Artificial Joints

Diabetes

Jaw Pain

Stroke



Asthma

Epilepsy

Kidney Disease

Swelling of Feet or Ankles



Back Problems

Fainting

Liver Disease

Thyroid Problems



Blood Disease

Glaucoma

Mitral Valve Prolapse

Tobacco Habit



Cancer

Headaches

Pacemaker

Tonsillitis



Chemical Dependency

Heart Murmur

Radiation Treatment

Tuberculosis



Chemotherapy

Heart Problems

Respiratory Disease

Ulcer



Circulatory Problems

Hemophilia

Rheumatic Fever

Venereal Disease

UTHORIZATION



I understand that the information that I have given today is correct to the best of my knowledge. I also

understand that this information will be held in the strictest of confidence and it is my responsibility to

inform the office of any changes in my child’s medical status.



I hereby authorize the release of any information pertaining to my child’s medical treatment necessary to

process any insurance claims. I further authorize the application for benefits on my behalf for covered

services and payment of any benefits to the office. I understand that I am responsible for any amount not

covered by insurance.



I understand that where appropriate, credit bureau reports may be obtained.

___________________________________________________________

___________

Patient Signature and/or Responsible Party

Date

New Child Patient Form Page 3

Related Articles

Related forms

Related Categories