11-12 Year-Old Forms Interim HistoryHIPAAChildrens Healthy HabitsCholesterol ScreenSports Physical & History Interim History Interim History Update Child's Name * DOB * (MM/DD/YYYY) Street * City * State * Zip * Current Contact Information Mom's Name Mom's Phone Mom's Relationship Biologic Adoptive Mom's Email Confirm Mom's Email Email verification Stepmother's Name Stepmother's Phone Stepmother's Email Confirm Stepmother's Email Email verification Father's Name Father's Phone Father's Relationship Biologic Adoptive Father's Email Confirm Father's Email Email verification Stepfather's Name Stepfather's Phone Stepfather's Email Confirm Stepfather's Email Email verification Legal Guardian Name Legal Guardian Phone Legal Guardian Email Confirm Legal Guardian Email Email verification Insurance Company Member ID If there are any changes in parent's or grandparents' health which you do not want to discuss in front of your child, then please elaborate. Interim Medical History arrowup6 1. Surgeries or Procedures (including endoscopy, EKG, dental work, etc) since last well check 2. Dates and reasons for overnight hospitalizations since last well check 3. Name, specialty, and date seen for any specialist visit since last well check Current Prescription Oral Medications arrowup6 1. Oral medication 1. Dose 2. Oral medication 2. Dose 3. Other Oral Meds/Doses Current Prescription Topical Medications (creams, etc.) arrowup6 1. Topical medication 1. Dose 2. Topical medication 2. Dose 3. Other Topical Meds/Doses Current Prescription Inhaled Medications arrowup6 1. Inhaled medication 1. Dose 2. Inhaled medication 2. Dose 3. Other Inhaled Meds/Doses Current Over-the-Counter Medications arrowup6 1. Medication 1. Dose 2. Medication 2. Dose 3. Other Meds/Doses Allergies arrowup6 1. Medication 2. Medication 1. Food 2. Food 3. Other Allergies Environmental Primary water source (for children under six) Well water City water Bottled water Does this child (if under age three) live in or frequently visit a house constructed before 1978? Yes No Section Parent or Legal Guardian Signature signature keyboard Clear If you are human, leave this field blank. Submit HIPAA Form HIPAA Consent to Treat (Select Appropriate Clinic) For which clinic is this form? * logo required delete move drag clear noclear duplicate copy clone tooltip tooltip_solid forbid checkmark image checkmark circle checkmark square check check1 plus plus1 plus2 plus3 plus4 minus minus1 minus2 minus3 minus4 cancel cancel1 close report_problem_solid report_problem arrowup arrowup1 arrowup2 arrowup3 arrowup4 arrowup5 arrowup5_solid arrowup7 arrowup6 arrowdown arrowdown1 arrowdown2 arrowdown3 arrowdown4 arrowdown5 arrowdown5_solid arrowdown7 arrowdown6 arrow_left arrow_right filter download upload2 download2 hard_drive pencil_solid pencil signature register account_circle_solid account_circle address_card paragraph checkbox_unchecked checkbox checkbox_solid dropdown caret_square_down radio_unchecked scrubber location_solid location toggle_on toggle_off shield_check shield_check_solid clock clock_solid email_solid mail_bulk code tag tag_solid price_tags search sitemap file file_text_solid file_text option option_solid more_horiz more_vert more_horiz_solid more_vert_solid calculator key key Filled Key Icon keyboard eye eye_solid eye_slash_solid page_break view_day attach_file printer header h1 repeat repeater save sliders code_commit star star_full star_half linear_scale pie_chart stats_bars sms highrise mailchimp feed align_right align_left button browser cloud_upload_solid shuffle swap pallet fingerprint ghost heart_solid heart history import export label_solid label lock_open lock alt_lock dollar_sign percent notification external_link pageview_solid pageview settings stamp support text white_label authorize activecampaign aweber campaignmonitor constant_contact getresponse googlesheets building hubspot icontact mailpoet paypal icon sendinblue sendy salesforce salesforcealt stripe stripealt twilio woocommerce wordpress credit_card credit_card_alt cc_amex cc_discover cc_mastercard cc_visa cc_paypal icon cc_stripe price product total quantity directory Zapier Preview Storybook Pediatrics G. F. Still ADHD Clinic Date * (MM/DD/YYYY) Child's Name * Parent(s) Names * Persons (other than parents) who have permission to obtain medical care for my children: * I (we), the legal quardians of the above named children do hereby give my(our) consent for the persons listed below to obtain medical care for my (our) children at Storybook Pediatrics. I (we) understand that by giving persons permission to take my child/children to Storybook Pediatrics for medical care, I am also giving Storybook Pediatrics permission to disclose my child's (children's) protected health information to any of the persons on this list. I also understand that by giving these persons permision to take my child (children) to Storybook Pediatrics for medical care that I am also giving these persons my permission to make medical care decisions for my child (children) during those visits. Parent or Legal Guardian Signature: * I (we) agree to this medical consent Signature * signature keyboard Clear If you are human, leave this field blank. Submit Healthy Habits Child Healthy Habits (Child) Email to receive your copy (Optional) Confirm Email to receive your copy (Optional) Enter a confirmation email address. Date * (MM/DD/YYYY) Patient * DOB * (MM/DD/YYYY) Questions 1. My child eats this many servings of veggies a day (a serving is about the size of your fist) 0-1 servings 2-3 servings 3-4 servings more than 4 servers 2. My child eats this many servings of fruits a day (a serving is about the size of your fist) 0-1 servings 1-2 servings 3-4 servings more than 4 servings 3. My child eats out More than 4 times a week 3-4 times a week 1-2 times a week 0-1 time a week 4. My child is active Not very often Less than 30 minutes a day 30-60 minutes a day More than 60 minutes a day 5. My child has sweet drinks soda, sweet tea, 100% fruit juice, sports drinks, other fruit drinks) More than 3 cups a day 2 cups a day 1 cup a day Not very often 6. My child watches television, plays video games, spends (non-school related) time on the computer, table, or cell phone More than 2 hours a day 1-2 hours a day 30-60 minutes a day Not very often 7. Most nights, my child sleeps Less than 7 hours 7-8 hours 9-10 hours More than 10 hours 8. If you could work on one healthy habit, which would it be? Make half your plate veggies and fruits Limit screen time Be more active Drink more water and limit sugary drinks Get the right amount of sleep I am not ready to work on a healthy habit If you are human, leave this field blank. Submit Cholesterol Cholesterol Patient * DOB * (MM/DD/YYYY) Questions 1. Is this child adopted? * Yes No 2. Are the medical records available or medical history known for parents or grandparents? * Yes No 3. Has either parent or any grandparents experience any of the following? Check all that apply. Mother or grandmother under the age of 65 who has had a heart attack, stroke, or blocked arteries Father or grandfather under the age of 55 who has had a heart attack, stroke, or blocked arteries Total cholesterol over 240mg/dl 4. Is this child overweight? * Yes No 5. If your child has risk factors for high cholesterol or early heart disease, are you interested in screening labs? * Yes No Special Note FAQ Sheet: Lipid Panels9/8/23 The AAP recommends lipid screening beginning at age 8 years for the following populations: *Obese children: defined as a BMI greater than the 95% for age (E66.9) *Children whose parents or grandparents have had a heart attack, stroke, or blocked arteries younger than 65 in women and 55 in men (Z82.41, Z82.49) *Children who have a parent or grandparent with a total cholesterol of 240 mg/dl or higher (Z83.42) *Children whose family history is unknown. (Z84.89) (Source: healthychildren.org 8/20/2020) We at Storybook Pediatrics also recommend this screening. We do recommend that you check with your insurance company prior to this lab draw to ensure that they will cover these labs. The codes for the diagnoses are listed above. You can provide your insurance company with the appropriate codes If your child is obese, we recommend the following labs: Lipid panel Hemoglobin A1C AST/ ALT If there is relevant family history or family history is unknown, we recommend the following: Lipid panel Alternatively, if you wish to do so, we can send the labs as self pay. The self pay prices are listed below for Lab Corp. Our phlebotomist can draw these labs and send them to the lab. Lipid Panel: $102.90 Hemoglobin A1C: $69.30 ALT/AST: $77.70 Submit If you are human, leave this field blank. Preparticipation Physical History 2023 Sports Pre-participation History Email to receive your copy (Optional) Confirm Email to receive your copy (Optional) Enter a confirmation email address. Name * DOB * (MM/DD/YYYY) Date of Exam (MM/DD/YYYY) Biologic Sex * MaleFemale Sport(s) * Past & Current Medical Conditions Surgical History Medications and supplements Allergies Over the last 2 weeks have you experienced any of the following (check all that apply!) Feeling nervous, anxious, or on edge Not at all Several days Over half the days Nearly every day Not begin able to stop or control worrying Not at all Several days Over half the days Nearly every day Little interest or pleasure in doing things Not at all Several days Over half the days Nearly every day Feeling down, depressed, or hopeless Not at all Several days Over half the days Nearly every day GENERAL QUESTIONS. Explain "Yes" answers. 1. Do you have any concerns that you would like to discuss with your provider? Yes No 2. Has a provider ever denied or restricted your participation in sports for any reason? Yes No 3. Do you have any ongoing medical issues or recent illness? Yes No HEART HEALTH QUESTIONS ABOUT YOU 4. Have you ever passed out or nearly passed out during or after exercise? Yes No 5. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? Yes No 6. Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise? Yes No 7. Has a doctor ever told you that you have any heart problems? Yes No 8. Has a doctor ever requested a test for your heart? For example, electrocardiography (ECG) or echocardiography. Yes No 9. Do you get light-headed or feel shorter of breath than your friends during exercise? Yes No 10. Have you ever had a seizure? Yes No HEART HEALTH QUESITONS ABOUT YOUR FAMILY 11. Has any family member or relative died of heart problems or had an unexpected or unexplained sudden death before age 35 years (including drowning or unexplained car crash)? Yes No 12. Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy (HCM), Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy (ARVC), long QT syndrome (LQTS), short QT syndreme (SQTS), Brugada syndrome, or catecholaminergic polymorphic ventrciular tachycardia (CPVT)? Yes No 13. Has anyone in your family had a pacemaker or an implanted defibrillator before age 35? Yes No BONE AND JOINT QUESTIONS 14. Have you ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused you to miss a practice or game? Yes No 15. Do you have a bone, muscle, ligament, or joint injury that bothers you? Yes No OTHER MEDICAL QUESTIONS 16. Do you cough, wheeze, or have diffculty breathing during or after exercise? Yes No 17. Are you missing a kidney, an eye, a testicle (males), your spleen, or any other organ? Yes No 18. Do you have a groin or testicle pain or a painful bulge or hernia in the groin area? Yes No 19. Do you have any recurring skin rashes or rashes that come and go, including herpes or methicillin-resistant Staphylococcus aureus (MRSA)? Yes No 20. Have you had a concussion or head injury that caused confusion, a prolonged headache, or memory problems? Yes No 21. Have you ever had numbness, had tingling, had weakness in your arms or legs, or been unable to move your arms or legs after being hit or falling? Yes No 22. Have you ever become ill while exercising in the heat? Yes No 23. Do you or does someone in your family have sickle cell trait or disease? Yes No 24. Have you ever had or do you have any problems with your eyes or vision? Yes No 25. Do you worry about your weight? Yes No 26. Are you trying to or has anyone recommended that you gain or lose weight? Yes No 27. Are you on a special diet or do you avoid certain types of foods or food groups? Yes No 28. Have you ever had an eating disorder? Yes No Explain all Yes answers Briefly, explain all "Yes" answers here (256 character maximum). Signature of athlete signature keyboard Clear Signature of parent or guardian signature keyboard Clear Date * (MM/DD/YYYY) Submit If you are human, leave this field blank.
