New General Pediatric Patient History- Ages Six To Eighteen Years

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Child's Name
Child's Address
Child's Sex
Child's Approximate Age-Pick The Age Closest To The Child's Actual Age
Parent Or Other Caretaker Name
Parent Or Other Primary Caretaker Address
Parent/Other Caretaker's Relationship To The Child
At Approximately How Many Weeks Of Gestation Was The Child Born?
How Was The Child Delivered?
What Is Your Understanding Of How The Child Is Doing In School?
Vaccines That May Be Given At Birth-Check All Given
Vaccines Typically Given At Age Two Months-Check All Given
Vaccines That May Be Given At Age Two Months For Catch-up, Check All Given
Vaccines Typically Given At Age Four Months-Check All Given
Vaccines That May Be Given At Age Four Months For Catch-up, Check All Given
Vaccines Typically Given At Age Six Months-Check All Given
Vaccines That May Be Given At Age Six Months For Catch-up, -Check All Given
Vaccines Typically Given At Age Nine Months-Check All Given
Vaccines That May Be Given At Age Nine Months For Catch-up, Check All Given
Vaccines Typically Given At Age Twelve Months, Fifteen, or Eighteen or Months-Check All Given
Vaccines That May Be Given At Age Twelve or Fifteen Months Months For Catch-up, Check All Given
Vaccines Typically Given At Age Two To Four Years-Check All Given
Vaccines Typically Given At Age Eleven To Thirteen Years-Check All Given
What Foods Does The Child Take Each Day? Check All That Apply:
Does The Child Spend More Time Playing Outside In Either Organized Or Informal Activities Or Inside?
Does the child seems overweight or underweight to you?
Does The Child Wear A Helmet When Riding A Bicycle?
Does The Home Have All Required Smoke And Carbon Monoxide Detectors Installed?
Do You Have Any Concerns That The Child Is Being Abused Or At Risk Of Child Abuse At Home, At Other Homes, At School, Or In The Community?
If There Are Any Firearms Or Ammunition In The Home, Are They Properly Secured?
Is The Child's Mother Alive And Well?
Is The Child's Father Alive And Well?
Is The Child's Maternal Grandmother Alive And Well?
Is The Child's Maternal Grandfather Alive And Well?
Is The Child's Paternal Grandmother Alive And Well?
Is The Child's Paternal Grandfather Alive And Well?
How Many Living Siblings Does This Child Have?
Are Any Of The Child's Siblings Deceased?
Who Is/Are The Child’s Primary Caretakers? Check All That Apply
Who All Has Legal Custody Of The Child? Check All That Apply.
I authorize BayCare Medical Group to treat my child for pediatric care.
I authorize BayCare Medical Group to file health plan claims on my behalf.
Email Communication Authorization: I give permission for BayCareMedical Group And Its Doctors To Communicate With Me RegardingThe Child's Care By Telephone, Text Message, or Email.

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HIPPA Notice Provided?
Required Medical Board of California Notice To Consumers: Richard B. Fox, M.D.,J.D., CA Medical License #G67169 provides this NOTICE TO CONSUMERS: Medical doctors are licensed and regulated by the Medical Board of California (800) 633-2322, www.mbc.ca.gov. Click "yes" to acknowledge receipt of this legally required notice.
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