3-Year Forms 3-Year Forms The CMS (Centers for Medicare & Medicaid Services) and the American Academy of Pediatrics have respectively required and recommended all the patient forms. All insurance companies are requiring us to have these completed for reimbursement. We apologize for any inconvenience this causes. We apologize for any duplicate fields in these forms. HIPAA Consent to Treat (Select Appropriate Clinic) For which clinic is this form? * logo acf-forms activecampaign authorize aweber bootstrap campaignmonitor constant_contact getresponse googlesheets highrise hubspot mailchimp mailpoet paypal icon polylang salesforce salesforcealt stripe stripealt twilio woocommerce Zapier 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 arrowup8 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 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 building icontact sendinblue sendy wordpress credit_card credit_card_alt cc_amex cc_discover cc_mastercard cc_visa cc_paypal icon cc_stripe price product total quantity directory 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 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 MCHAT Child's Name * DOB * MM/DD/YYY Parent or Guardian & Relationship * Questions 1. If you point at something across the room, does your child look at it? (For example, if you point at a toy or an animal, does your child look at the toy or animal?) * Yes No 2. Have you ever wondered if your child might be deaf? * Yes No 3. Does your child play pretend or make-believe? (For example, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?) * Yes No 4. Does your child like climbing on things? (For example, furniture, playground equipment, or stairs.) * Yes No 5. Does your child make unusual finger movements near his or her eyes? (For example, does your child wiggle his or her fingers close to his or her eyes?) * Yes No 6. Does your child point with one finger to ask for something or to get help? (For example, pointing to a snack or toy that is out of reach.) * Yes No 7. Does your child point with one finger to show you something interesting? (For example, pointing to an airplane in the sky or a big truck in the road.) * Yes No 8. Is your child interested in other children? (For example, does your child watch other children, smile at them, or go to them?) * Yes No 9. Does your child show you things by bringing them to you or holding them up for you to see—not to get help, but just to share? (For example, showing you a flower, a stuffed animal, or a toy truck.) * Yes No 10. Does you child respond when you call his or her name? (For example, does he or she look up, talk or babble, or stop what he or she is doing when you call his or her name?) * Yes No 11. When you smile at your child, does he or she smile back at you? * Yes No 12. Does you child get upset by everyday noises? (For example, does your child scream or cry to noises such as a vacuum cleaner or loud music?) * Yes No 13. Does your child walk? * Yes No 14. Does your child look you in the eye when you are talking to him or her, playing with him or her, or dressing him or her? * Yes No 15. Does your child try to copy what you do? (For example, wave bye-bye, clap, or make a funny noise when you do.) * Yes No 16. If you turn your head to look at something, does your child look around to see what you are looking at? * Yes No 17. Does your child try to get you to watch him or her? (For example, does your child look at you for praise, or say "look" or "watch me?") * Yes No 18. Does your child understand when you tell him or her to do something? (For example, if you don't point, can your child understand "put the book on the chair," or "bring me the blankets?") * Yes No 19. If something new happens, does your child look at your face to see how you feel about it? (For example, if he or she hears a strange or funny noise, or sees a new toy, will he or she look at your face?) * Yes No 20. Does your child like movement activities? (For example, being swung or bounced on your knee.) * Yes No 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
