NEWBORN HISTORY (BIRTH TO 2 YEARS)

Transcription

1 NEWBORN HISTORY (BIRTH TO 2 YEARS) Today s Date: Child s Name: The following questions are designed to help the doctor provide the best possible spinal care for your child. How many hours does your child sleep between feeds? During day at night COMMENTS YES NO Does your baby go to sleep easily? 0 0 Does baby have a preferred sleeping position? 0 0 Does baby cry if you change this sleeping position? 0 0 Does baby have any feeding difficulties? 0 0 Is baby breast fed? 0 0 If no, for how long was baby breast fed? Weeks/Months Does baby have a one sided breast-feeding preference? 0 0 Preferred breast Left/Right Is baby formula fed? Which formula or other milk source? 0 0 Does baby frequently spit-up after feeding? 0 0 Does baby cry a lot? For how many hours each day? 0 0 Does baby pass a lot of intestinal gas? 0 0 Does baby have a preferred head position? 0 0 Does baby frequently arch his/her head and neck backwards? 0 0 Does baby cry or become irritable during diaper change? 0 0 Has baby ever had a fever? 0 0 Has baby had any falls? 0 0 Has baby been in a car accident or near-miss? 0 0 Has baby had any other trauma? 0 0 Do you have any other concerns you wish to discuss? 0 0 THIS SECTION FOR CLINIC USE ONLY

2 Today s Date: PREGNANCY HISTORY Child s Name: How many children do you have? What was the term of your pregnancy? weeks. DURING YOUR PREGNANCY, DID YOU HAVE ANY OF THE FOLLOWING? EXPLAIN YES NO Falls 0 0 Motor Vehicle Accident(s) 0 0 Near-Miss MVA 0 0 High Blood Pressure 0 0 Diabetes 0 0 Anemia 0 0 Morning Sickness 0 0 Indigestion 0 0 Seizures 0 0 Swollen Ankles 0 0 Thyroid Problems 0 0 Heart Problems 0 0 Back Pain 0 0 Abnormal Bleeding 0 0 Were you hospitalized 0 0 Any other illness 0 0 Any other information you wish to add about your pregnancy;

3 Child s Name: BIRTH HISTORY LABOR AND DELIVERY How long was the labor from the first regular contractions to birth? hours. How long was the 2 nd stage (the pushing phase) of the labor? mins. Please answer the following questions and give explanation where necessary. YES NO Hospital Birth 0 0 Home Birth 0 0 Midwife assisted 0 0 Vaginal Delivery 0 0 Planned C-Section 0 0 Emergency C-Section 0 0 Induced birth (Pitocin) 0 0 Forceps delivery 0 0 Vacuum extraction 0 0 Head presentation 0 0 Face presentation 0 0 Breech presentation 0 0 THIS SECTION FOR CLINIC USE ONLY

4 PEDIATRIC NEW PATIENT INFORMATION Today s Date: PATIENT INFORMATION Child s Name: M/F Date of Birth: Child s Nickname: FAMILY INFORMATION Mother s Name: Address: City State Zip Home Phone: Cell: Work: Father s Name: Address (If different than Mother s) City State Zip Home Phone: Cell: Work: INSURANCE INFORMATION Primary Insurance: Name of Insured: Date of birth of insured: Secondary Insurance: Name of Insured: Date of birth of insured: CONSENT TO TREAT Being the parent or legal guardian of this child, I hereby authorize this office and its doctors to examine and administer care to my son/daughter named above as the examining/treating doctor deems necessary. I understand and agree that I am personally responsible for payment of all fees charged by this office for such care regardless of what my insurance company covers. I hereby authorize Perreault Chiropractic to seek payment and authorize/assign payment directly to them from my insurance company. PARENT GUARDIAN SIGNATURE:

5 Consent to the Use and Disclosure of Health Informaton for treatment, payment, or healthcare operatons. I understand that as part of my healthcare, Perreault Chiropractc & Acupuncture originates and maintains health records describing my health history, symptoms, examinaton and test results, diagnoses treatment, and any future plans for care or treatment. I understand that this informaton serves as: A basis for planning my care and treatment. A means of communicaton among the many healthcare professionals who contribute to my care. A source of informaton for applying my diagnosis and surgical informaton to my bill. A means by which a third-party payer can verify that services billed were actually provided. A tool for routne healthcare operatons such as assessing quality and reviewing the competence of healthcare professionals. I understand that a Notce of Privacy Practces is available at my request which provides a more complete descripton of informaton uses and disclosures. I understand that I have the right to review the notce prior to signing this consent. I understand that Perreault Chiropractc & Acupuncture reserves the right to change their notce and practces and prior to implementaton will mail a copy of any revised notce to the address Iave provided. I understand that I have the right to objeect to the use of my health informaton for directory purposes. I understand that I have the right to request restrictons as to how my health informaton may be used or disclosed to carry out treatment, payment, or healthcare operatons and that Perreault Chiropractc is not required to agree to the restrictons requested. I understand that I may revoke this consent in writng, except to the extent that Perreault Chiropractc & Acupuncture has already taken acton in reliance thereon. Signature: Date:

6 Patent Financial Responsiޣility PolicyAuuthoriaaton & ussinnment of eeneits General The patentas insurance policy is a contract between the patent and his or her insurance company. However, all charnes renardless of the insurance coverane are the patentts responsiޣility and the patent is ultmately responsible for any unpaid balances. As a courtesy to our patents, PC & A bills the patentsa insurance and makes every effort to ensure that claims are promptly and correctly processed. PC & A also bills patentsa secondary insurance when patents provide complete insurance informaton. Patent co-pays are expected at the tme of service, and any remaining payment is due within g0 days of receiving the frst bill from PC & A. We accept cash, checks, money orders, debit cards and credit cards (Visa, Master Card, Discover and American Express). If you canat pay your balance within g0 days, please contact our ofce and we will work with you to fnd a monthly payment amount that will work with your fnancial needs. If no insurance informaton is provided, or the correct informaton is not provided within the allowed amount of tme set by the insurance company, the patent will be fully responsible for charges incurred. Past Due ealances A past due balance is any amount owed afer the insurance company has paid its porton, but where PC &A has not received the full patent balance within ninety (90) days. Patients who hoavie a prievi us c lliect n agiency balancie and wisho t riecieivie siervicies arie riequiried t pay any niew choargies at thoie tiie o sierviciee. I hereby authorize Perreault Chiropractc & Acupuncture to release to my insurance company informaton necessary for them to process my claims for care. I also assign insurance benefts to Perreault Chiropractc & Acupuncture as may be allowed by my insurance company. I further understand that I am fully responsible for all the charges incurred at Perreault Chiropractc & Acupuncture, regardless of my insurance coverage. Please note: We will do all we can to ensure your care is covered by your insurance carrier. However, benefts quoted to us are not a guarantee of payment but a general outline of your coverage. If a problem arises, we will appraise you as soon as possible and will expect you to call your insurance carrier to clear up any problems. Please keep in mind your contract is between you and your insurance carrier. We do not have any legal rights to your insurance contract you do. Please be aware that many insurance carriers can take up to g months or more to process a claim. Patent Name: Signature: Date:

7 Patient Messaging Consent By supplying my home phone number, mobile phone number, address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach and messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of an upcoming appointment, a missed appointment, balances due, or other communications. I also authorize my healthcare provider to disclose to third parties, who may intercept these messages, limited protected health information (PHI) regarding my healthcare events. I consent to receiving multiple messages per day from the automated outreach and messaging system, when necessary. Patent Name Date Patent Signature Cell number: Please send me text reminders for my upcoming appointments cell phone provider: Circle how far in advance you would like the reminders to be sent 15 mins g0 mins 1 hr 2 hrs 4 hrs 1 day 2 days 1 week