4-7 Year Forms 4 to 7-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? * Storybook Pediatrics G. F. Still ADHD Clinic Date * (MM/DD/YYYY) Child's Name * Parent(s) Names * Persons (other than parents & over the age of 18 years) 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 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 Submit If you are human, leave this field blank.
