Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at

Full text

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Patient DOB Atlanta, GA 30342

Your child has been referred to the Health4Life

Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the

Medical Office Building.

In order to serve you and your child better, we require that all information in this packet must be

completed and returned to us prior to making an appointment.

Please review, complete, and return all paperwork included in this packet.

If you have any questions or concerns please feel free to contact us at

Phone 404-785-1535

Fax 404-785-1511

Email Health4Life@choa.org

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New Patient Intake Form

Patient:

Patient's Legal Name (Last, First, Middle) Date of Birth:

Age Sex Race Religion

Home Address

City State

Zip Code Preferred Phone Number

Father/Guardian

Father's Name Date of Birth:

Address (if different than above)

City State

Zip Code

Home Number Cell Number Work Number

Mother/Guardian

Mother's Name Date of Birth:

Address (if different than above)

City State

Zip Code

Home Number Cell Number Work Number

Emergency Contacts (other than listed above)

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Patient DOB Atlanta, GA 30342

Insurance Information

Please complete information below about your child's insurance coverage. Everything can be found by looking at your current insurance card.

Feel free to make a copy of the front and back of your insurance card to include in the packet if you find this easier.

Primary Insurance

Insurance Company's Name Plan Name

Insurance Subscriber's Name Subscriber's Date of Birth Relationship to Patient

Employer Group Name Phone Number

Subscriber/Member ID Address Listed

Group Number

Secondary Insurance

Insurance Company's Name Plan Name

Insurance Subscriber's Name Subscriber's Date of Birth Relationship to Patient

Employer Group Name Phone Number

Subscriber/Member ID Address Listed

Group Number

Important Billing & Insurance Information

You or your insurance company will receive, at minimum, 2 bills. One bill will be for hospital services rendered as part of your visit (includes facility charge, labs, radiology, & therapies) and the others will be for each doctor your child sees at

the visit.

Separate co-payments or deductibles for which you are responsible for may be applied to each bill depending on your individual arrangement with your insurance company. If your child sees multiple doctors at your visit, you may be

required to pay co-payments for each doctor seen.

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1. Background Information

Your Child’s Primary Doctor: Physician Phone: Pharmacy Phone:

Mother: Occupation: Age: Father: Occupation: Age: Who lives in the same home as your child:

Reason for visit to the Health4Life Program:

2. History of Current Problem

What is your main concern?

At what age did weight become a concern?

What things have you tried for weight or weight related problems?

Please write down any other concerns about your child’s health:

3. Past Medical History

Immunizations up to date: Yes No Medicine Allergies: Yes No If yes list:

Pregnancy Complications: Yes No Food Allergies: Yes No If yes list:

Birth History: Birth Weight: Premature Birth Yes No If Yes: how early? Has your child ever had an operation Yes No List:

Has your child ever been hospitalized Yes No List:

Does your CHILD have any of the following conditions: ADHD Anxiety Disorder Asthma Bleeding Disorder Celiac Disease Depression Developmental Delay Diabetes Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Eczema GI Reflux Heart Disease High Blood Pressure Immunologic Disease

Inflammatory Bowel Disease

Kidney Disease Learning Disability Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Liver Disease Migraine Headaches Seasonal Allergies Seizure Disorder Thyroid Disease Yes No Yes No Yes No Yes No Yes No

Other Past Medical History:

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Patient DOB Atlanta, GA 30342

4

.

Family History

Is there a Family History (i.e Mother, Father, Siblings, Grandparents) of any of the following:

Who? Who? Who?

Anxiety Disorder ADHD Asthma Cancer/Leukemia Celiac Disease Depression Diabetes Eczema Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Environmental Allergies Gastroesphageal Reflux Heart Disease

High Blood Pressure High Cholesterol Immunologic Disease Inflammatory Bowel Disease Joint Disease Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Kidney Disease Liver Disease Migraine Headaches Seizure Disorder

Sudden Death (heart)

Thyroid Disease Weight Gain Yes No Yes No Yes No Yes No Yes No Yes No Yes No 5. Social History

Number of adults in household: Smoking in home: Yes No Pets in home: Yes No

Number of children in household: Ages of children:

Is your child in daycare? Yes No Is your child in school? Yes No Grade:

Favorite Activities outside of school:

6. Review of Systems (check all that apply to your child)

Neurological Headaches Dizzy Spells Endocrine Excessive Thirst Too Hot/Cold Tired/Sluggish Frequent Urination Excess Hair Eyes Blurred Vision Double Vision Cardiovascular Chest Pain Short of Breath Swelling Legs High Blood Pressure

Fainting Gastrointestinal Abdominal Pain Nausea/Vomiting Indigestion/heartburn Respiratory Wheezing Frequent Cough Shortness of Breath Integumentary (Skin) Skin Rash Boils Persistent Itch Acne Sleep Snores a lot Trouble Falling Asleep

Sleepy During Day

Genitourinary Painful Urination

Concerns About Penis or Vagina Menstrual Cycle

Date of First Period _______________ Date of Last Period________________

7. Please List Your Child’s Medications Constitutional Symptoms

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Physical Activity Log

Day

Type of Physical Activity

(i.e. walking, running, play basketball, free play, etc.)

of Physical Activity

Total Minutes

Monday

Wednesday

Saturday

Screen Time Log

Day

What type of screen time?

(TV, video-games, cell-phone

texting, computer)

Total amount of

time (hours)

What snacks were

eaten during the

screen time?

Does your child

have TV in their

room?

Monday

Wednesday

Figure

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References

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