Child Patient History Form

Step 1 of 15

Which location did you make an appointment with?(Required)

Patient Information

Patient's Name:(Required)

First Last

Date of Birth:(Required)

Month

Day

Year

Home Address:(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone:

Cell Phone:(Required)

Employer:

Work Phone:

Marital Status:

Gender:(Required)

Male

Female

Pharmacy Name:

Pharmacy Address:(Required)

Street Address Address Line 2 City State ZIP Code

Pharmacy Phone:(Required)

Primary Physician:(Required)

Physician's Phone:(Required)

Physician's Address:

Street Address Address Line 2 City State ZIP Code

Source of Referral:(Required)

Parent/Guardian/Emergency Contact Information

Mother's Name:

First Last

Home Phone:

Address:

Street Address Address Line 2 City State ZIP Code

(If different from patient’s address.)

Mother's Employer:

Mother's Occupation:

Mother's Work Phone:

Mother's Cell Phone:

Email:

Father's Name:

First Last

Home Phone:

Address:

Street Address Address Line 2 City State ZIP Code

(If different from patient’s address.)

Father's Employer:

Father's Occupation:

Father's Work Phone:

Father's Cell Phone:

Email:

Insurance Information

Primary Insurance Company's Name:

Phone:

Policy Holder's Name:

Date of Birth:

Month

Day

Year

Relationship to Patient:

EDI/Payer ID:

Polilcy Holder's ID#:

Group #:

Claims Address:

Street Address Address Line 2 City State ZIP Code

Patient History Questionnaire

Child's Name(Required)

Birthday(Required)

Month

Day

Year

Person Completing Questionnaire & Relationship to Patient(Required)

Purpose of Evaluation

What are your questions or concerns regarding your child?(Required)

Pregnancy & Birth History

Is this your biological or adopted child?(Required)

Biological Child

Adopted Child

At what age did you adopt this child?(Required)

Is the child aware of the adoption?(Required)

Yes

Did you have any health problems during your pregnancy with this child?(Required)

Yes

Please describe nature of these complications such as infection, bed rest, high blood pressure, etc.(Required)

Did you take any medications or use any drugs, alcohol, or tobacco during pregnancy?(Required)

Yes

Please list/descirbe any medications, drugs, alcohol or tobacco usage during pregnancy.(Required)

Was your baby carried for a full nine months?(Required)

Yes

Please indicate the length of pregnancy.(Required)

Did your baby need any special care after delivery?(Required)

Yes

Please describe the special care that your baby received after delivery.(Required)

How much did your baby weigh at birth?(Required)

Past Medical History

Has your child ever been hospitalized?(Required)

Yes

Please describe the reason and what age this occurred.(Required)

Has your child ever had any serious accidents or head injuries?

Yes

Please describe and include your child's age.(Required)

Has your child had any serious or chronic illnesses (asthma, allergies, diabetes, etc)?(Required)

Yes

Please describe and state if it has resolved.(Required)

Has your child ever had a seizure?(Required)

Yes

Please state at what age.(Required)

Has your child ever had any tics (repetitive facial movements, throat clearing, sniffing, eye blinking, etc.)?(Required)

Yes

Please explain.

Is your child taking any medications?(Required)

Yes

Please list medication and dosage.(Required)

Does your child have any allergies to medications?(Required)

Yes

Please list the medications.(Required)

Do you have concerns about your child’s eating habits?(Required)

Yes

Please describe.(Required)

Do you have concerns about your child’s sleep?(Required)

Yes

Please describe.(Required)

Does your child complain of pain more than once a week (headaches, stomachaches)?(Required)

Yes

Please describe.(Required)

Development History

Did you have any concerns about your child's development?(Required)

Yes

Please explain.

At what age did your child:(Required)

Roll Over

Sit Alone

Crawl

Walk

At what age did your child begin saying:(Required)

Single Words

Combine Words

Did your child have any development therapies (OT, PT, Speech)?(Required)

Yes

Please describe & list at what age?(Required)

At what age did your child become toilet trained?(Required)

Does your child currently have any daytime accidents?(Required)

Yes

How often?(Required)

Does your child have any nighttime accidents?(Required)

Yes

How often?(Required)

Past Mental Health Treatment

Please list any previous medications that your child has been prescribed for mood, anxiety, attention or behavior and any side effects he/she may have experienced.(Required)

Has your child ever had any behavior therapy or counseling?(Required)

Yes

Please include your child’s age at the time and the name of the therapist.(Required)

Educational History

Please list the schools your child has attended:

Preschool

Name of School

Dates Attended

Elementary School

Name of School

Dates Attended

Middle School

Name of School

Dates Attended

High School

Name of School

Dates Attended

Please describe any educational services or resources that are provided to your child (IEP, 504 plan, special education services, etc.)

Please describe any extracurricular activities in which your child participates.

Please describe your child’s peer group and how he/she interacts with others.

Family History

Parents are:(Required)

Married

Separated

Divorced

Unmarried

Widowed

Date

Please describe custody arrangement & visitation:

Please list all people living in your home:(Required)

Name

Sex

Birthdate

Relationship to Child

Present or Highest Grade Completed

Please list family members who no longer live in the home with the child.(Required)

Name

Sex

Birthdate

Relationship to Child

Present or Highest Grade Completed

During the past 12 months has your family experienced any of the following:

Death of a Family Member

Serious Illness

Marital Problems

Unemployment

Other

Check all that apply

Please explain.(Required)

Have any family members experienced any of the following?

Depression

Anxiety

ADHD

Autism

Bipolar Disorder

Schizophrenia

Other Mental Health Diagnoses

Heart or Blood Pressure Problems

Consent to Treat

Consent to Treat(Required)

I hereby consent to treatment.

I hereby authorize Axon Health Associates, LLC and its respective personnel to provide evaluation and treatment to the patient listed above. I understand that these services are not guaranteed as to results, that no guarantees have been provided by Axon Health Associates, LLC, and that there are certain risks involved with these services. I understand that I can terminate this consent for treatment by requesting termination in writing.

If I am unable to attend the appointment as a guardian, I hereby authorize the following people to attend the appointment in my place:

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Patient/Legal Guardian Signature:

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Date Signed:

Month

Day

Year

Relationship to Patient:

Privacy Acknowledgement

Privacy Acknowledgement(Required)

I agree to the privacy policy.

I understand that the patient’s health information is private and confidential. I understand that with this consent, I give permission for aspects of my/my child’s private healthcare information to be shared with Axon Health Associates, LLC, as is necessary for services to be provided. I understand that Axon Health Associates, LLC may use and disclose the patient’s personal health information to help provide care to the patient, to handle billing and payment, and to take care of other health care operations. In general, there will be no other uses and disclosures of this information unless I permit it. I understand that sometimes the law may require the release of this information without my permission. By law, Axon Health Associates, LLC must report actual or suspected child or elder abuse to the appropriate authorities. In addition, Axon Health Associates, LLC is legally bound to take appropriate action if my child or I threaten anyone with violence, harm, or dangerous actions. I understand that there is a detailed document titled “Notice of Privacy Practices” that contains more information about the policies and practices protecting my privacy. I understand that I have the right to read the “Notice” before signing this acknowledgement. I am aware that a copy of this notice will be given to me upon my request or that it may be found at axonhealth.org. Axon Health Associates, LLC has established procedures which help meet patient obligations. These procedures may include other signature requirements, written acknowledgements, and authorizations; reasonable time frames for requesting information; charges for copies and non-routine information needs, etc. I will assist Axon Health Associates, LLC by following these procedures if I choose to exercise any of my rights described in the “Notice of Privacy Practices”. My signature below indicates that I have been given the chance to review a current copy of the “Notice of Privacy Practices”.

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Patient/Legal Guardian Signature:

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Date Signed:

Month

Day

Year

Relationship to Patient

Financial Agreement

Consent(Required)

I agree to the financial agreement policy.

I agree to pay in full, at the time of service, for all services rendered for myself or my child by Axon Health Associates, LLC, for any out-of-network services. I understand that there is a document available upon request or at axonhealth.org regarding the Fee Schedule and any financial obligations, and I have read and agree with the information in this document. For in-network services, I agree to pay for my copay at the time of service and understand that my insurance company will be billed for the remainder. I am aware that there is a document titled Insurance Tips that is available upon request or at axonhealth.org. This document will be helpful to understand what portion of the fees may be covered by my insurance plan. I understand that 24 hours notice of cancellation is required to avoid charges for missed appointments. I understand that in families where parents do not share the same household, payment for services is the responsibility of the parent who accompanies the child to the appointment.

I also understand and agree to pay for any services related to legal matters, including but not limited to depositions, attorney phone calls, and court testimony; these services may be a different pay rate.

I also understand and agree to pay for services including record retrieval, phone consultation, and email consultation as requested by the provider.

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Signature

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Date

Month

Day

Year

Relationship to Patient

Consent to Use Email Communications

I hereby agree to sending to and receiving from Axon Health Associates, LLC email communications as part of comprehensive treatment for my child. I understand the risks of sending PHI through email even with encryption, and with this agreement I am accepting these risks to my child’s PHI. I accept that Axon Health Associates, LLC shall not be held responsible for any exposure of email communications at my home or place of employment, depending on the location of my email address. I also understand that email communications can fail in their transmission, and I agree to contact Axon Health Associates, LLC if I have not obtained a response from my email communication within three business days. I also agree to never use email communications for emergency situations, and to call the office directly with any emergencies. I understand that I can terminate this agreement at any time by informing in writing. With my signature, I believe that the benefits of using email communications for my child’s healthcare outweigh the security risks.

I have read the Email Communications consent above and I(Required)

Agree to receive email communications from Axon Health Associates, LLC

Do Not Agree to receive email communications from Axon Health Associates, LLC

Date(Required)

Month

Day

Year

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