New Patient Registration Form
Patient Information
Name
*
First Name
Last Name
Sex
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Ethnicity
*
White
Black/ African American
Asian
Other
Primary Language
*
Parent 1
Name
*
First Name
Last Name
Maiden Name (if applicable)
Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Parent 2
Name
First Name
Last Name
Maiden Name (if applicable)
Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Guardian (if other than natural born parent)
Name
First Name
Last Name
Relationship to Patient
Patient Lives With
Both Parents
Mother
Father
Guardian
Health Insurance
*
Subscriber ID #
*
Policy Holder Name
*
First Name
Last Name
Policy Holder DOB
*
-
Month
-
Day
Year
Date
Primary Pharmacy
*
Primary Pharmacy Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primacy Pharmacy Phone Number
*
-
Area Code
Phone Number
Most Recent Healthcare Provider
*
Last Routine Well Visit Date
*
-
Month
-
Day
Year
Date
Has your child ever been a patient of any of the Medical Health Associates practicing locations (Island Pediatrics, Main Pediatrics, Suburban Pediatrics, Tonawanda Pediatrics, Transit Meadow Pediatrics, Williamsville Pediatric Center, WNY Pediatrics)?
*
Yes
No
Birth History
Pregnancy Complications
*
Delivery
Hospital
*
Type
*
Vaginal
C-Section
Gestational Age
*
Birth Weight
*
Length Of Stay
*
Complications
Patient Information
Hospitalizations
Surgeries
Medical - Please check if child has had the following
Chicken Pox
Seasonal Allergy
Asthma
Pneumonia
Heart Problems
Mononucleosis
Hives
Elevated Lead
Anemia
Broken Bones
Burns
TB Exposure
Urinary Tract Infection
Fainting
Eczema/ Skin Rash
Seizures
Head Trauma/ Concussion
Headaches/ Migraines
Depression/ Anxiety
Medications
Allergies
Immunizations
Is Your Child Up To Date
*
Yes
No
Provide Copy of Record
Browse Files
Cancel
of
Habits
Uses Car Seat/ Seat Belt
*
Yes
No
Trouble With Vision
*
Yes
No
Routine Dental Exams
*
Yes
No
Brushes Teeth Regularly
*
Yes
No
Frequent Colds
*
Yes
No
Frequent Sore Throats
*
Yes
No
Frequent Ear Infections
*
Yes
No
Constipation
*
Yes
No
Frequent Abdominal Pain
*
Yes
No
Frequent Muscle/ Joint Pain/ Swelling
*
Yes
No
Rashes
*
Yes
No
Trouble With Hearing
*
Yes
No
Breathing Problems
*
Yes
No
Easily Fatigued/ Tired
*
Yes
No
Feeding Problems
*
Yes
No
Bed Wetting
*
Yes
No
Urinary Problems
*
Yes
No
Easy Bruising/ Bleeding
*
Yes
No
Severe/ Frequent Headaches
*
Yes
No
Behavioral Problems
*
Yes
No
School/ Learning Problems
*
Yes
No
Stress In Family
*
Yes
No
Other information the doctor should be aware of
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Next
Family History
*
Yes or No
Who
Details
ADD/ ADHD
Asthma/ Wheezing
Allergies
Anemia
Alcoholism/ Drug Abuse
Autism
Autoimmune Disorders (Rheumatoid Arthritis, Lupus)
Birth Defects
Blood Disorder (Bleeding/ Clotting Problems, Sickle Cell, Anemia, Thalassemia)
Cancer
Diabetes
Eczema
Family Violence
Gastrointestinal Disorders
- GERD/ Reflux
- Celiac Disease
- Inflammatory Bowel Disease
- Irritable Bowel
Hearing Loss
Heart Attack/ Disease
- Sudden Cardiac Death
- Stroke
High Blood Pressure
High Cholesterol
Inherited/ Genetic Diseases
Kidney Disease
Liver Disease/ Hepatitis
Mental Illness
- Depression
- Anxiety
- Suicide Attempts
Intellectual Disability
Migraines
Seizures
Thyroid Disease
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Next
Family History Continued...
Has anyone in the family had an unexpected death under the age of 50?
Other Family Illnesses (please list)
Social History
Primary Household
Caretakers
*
Others In House
*
Pets
*
Smoking In House?
*
Yes
No
Secondary Household (if applicable)
Caretakers
Others In House
Pets
Smoking In House?
Yes
No
School
*
Grade
*
Daycare
Your Email
*
example@example.com
Submit
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