New Patient Registration Form

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
Primary Language *
Parent 1
Name *

First Name Last Name
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
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

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

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
Should be Empty:

New Patient Registration Form

Patient Information

Parent 1

Parent 2

Guardian (if other than natural born parent)

Birth History

Patient Information

Immunizations

Habits

Family History

Social History