Child Initial History CHILD INITIAL HISTORY FORMIf this is your child’s first visit to our practice, please fill out the following Initial History form before your visit. Note: If you would prefer to print a hard copy of the form and bring it with you on your visit, click here.After you have filled out the form, hit the submit button at the bottom of the screen. You will be redirected to a page indicating "Your Form Has Been Submitted to HFM." PROVIDER INFORMATIONPlease select your HFM location:* Clayton Four Oaks Riverwood Which Clayton Provider do you see?* Dr. Williams Dr. Harris Dr. Kahn Dr. McGill Dr. Selak Dr. Norris Megan Wester, PA Brittany McCall, FNP-C Jenah Manzano, PA-C Rebecca Johnson, FNP-BC Which Four Oaks Provider do you see?* Dr. Watson Dr. Olivia Johnson Hannah Brame, PA-C Which Riverwood Provider do you see?* Dr. Hebda Caroline Lewis, PA PATIENT INFORMATIONChild's Name (First, Middle, Last):*Date of Birth:*1. What is the reason for today's visit?*2. List all current medications:Medication NameStrengthHow often?How long have you been on it? 3. Are there any medication allergies?* Yes (specify medications and reactions) No Please list medications and reactions:4. Who is the previous Care Provider?Birth & Past Medical History5. Birth weight:*Length:*Delivered:* Vaginally by C-Section 6. Birth timing:* Full-Term (37-40 weeks) Late (> 40 weeks) Premature (< 37 weeks) 7. Hospital and City of Birth:*8. List any problems during pregnancy or delivery:9. List any medicine used during pregnancy:10. List any problems during newborn period:11. List previous Hospitalizations and/or Operations:Date of Hospitalization/OperationReason 12. Check any past medical problems the child has had:* Asthma Allergies Frequent ear infections Seizures Skin problems Food/formula intolerance Learning problems Heart problems/murmur NO MEDICAL PROBLEMS Feeding (only complete this section if child is less than 1 year old)13. Liquids: Breast Bottle Formula Type:Amount of juice per day:Amount of milk/formula per day:14. Solid foods:Fruit servings per day:Vegetable servings per day:Health Maintenance15. Are your child’s immunizations current?* Yes No Please upload an image of your child's immunization record, or provide a copy to the front desk.Upload file here: Drop files here or Select files Accepted file types: jpg, gif, png, Max. file size: 100 MB, Max. files: 1. HABITS16. Has your child had any unusual feeding or dietary problems?* Yes No 17. Has your child had any sleep problems?* Yes No 18. Do you live in a home built prior to 1972?* Yes No 19. Has your child been to the dentist?* Yes No 20. Do you use City Water?* Yes (specify city) No If City Water, what City?SCHOOL HISTORY21. Does your child attend daycare / preschool / school?* Yes (specify name) No Name of daycare / preschool / school:22. Any concerns about school performance or relationships?* Yes (specify) No School performance or relationship concerns:FAMILY HISTORY23. Please indicate if ANY family members have had the following:Alcoholism: Father Mother Brother Sister Asthma: Father Mother Brother Sister Autoimmune Disorder: Father Mother Brother Sister Bleeding Disorder: Father Mother Brother Sister Cancer: Father Mother Brother Sister Depression / Attention Problems: Father Mother Brother Sister Diabetes: Father Mother Brother Sister Genetic Problem: Father Mother Brother Sister Heart Disease: Father Mother Brother Sister High Blood Pressure: Father Mother Brother Sister Kidney Disease: Father Mother Brother Sister Stroke (CVS): Father Mother Brother Sister Substance Abuse: Father Mother Brother Sister Thyroid Problem: Father Mother Brother Sister SOCIAL HISTORY24. Who lives at home? (List names and relationship to patient)*25. Are the child’s parents:* Married Unmarried Separated Divorced (specify when) If divorced, when?26. What are the parents' occupations?Mother:Father:27. Who provides child care? Parents Safety28. Does the child ALWAYS:Wear a bike helmet when riding?* Yes No Wear a helmet, pads and wrist guards when rollerblading/skateboarding?* Yes No Ride in a secure car seat or wear a seatbelt in vehicles?* Yes No Wear sunscreen when outdoors?* Yes No 29. Is violence in the home a concern for you?* Yes No 30. Is there a gun in your home?* Yes No If there is a gun in your home, is it locked apart from the ammunition?* Yes No READ & SIGN BELOWI certify that the information provided is correct and complete to the best of my knowledge.Signature of Parent (or Legal Guardian):*Date:* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
