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Cook Islands
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Panama
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Virgin Islands, U.S.
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Primary Physician Address
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Belgium
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Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
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Greenland
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Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
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Hungary
Iceland
India
Indonesia
Iran
Iraq
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Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Source of Referral
(Required)
Parent/Guardian/Emergency Contact Information
Mother Name
(Required)
First
Last
Mother Employer
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Mother Occupation
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Mother Home Phone
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Mother Mobile Phone
Mother Address (if different)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Father Name
(Required)
First
Last
Father Home Phone
(Required)
Father Mobile Phone
Father Employer
(Required)
Father Occupation
(Required)
Father Address (if different)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Emergency Contact
Emergency Contact Name
(Required)
First
Last
Emergency Contact Home Phone
(Required)
Emergency Contact Mobile Phone
Emergency Contact Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
(If different from patient)
Insurance Information
Policy Holder Name
(Required)
First
Last
Policy Holder Birth Date
MM slash DD slash YYYY
Relationship to Patient
(Required)
Insurance Company Name
(Required)
Insurance Company Phone
(Required)
EID/Payer ID
(Required)
Policy Holder ID Number
(Required)
Group Number
(Required)
Claims Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
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Country
Consent to Treat
(Required)
I agree to the treatment policy.
I hereby authorize Axon Health Associates, LLC and its respective personnel to provide evaluation and treatment. I understand that these services are not guaranteed as to results, that no guarantees have been provided by Axon Health Associates, LLC, and that there are certain risks involved with these services. I understand that I can terminate this consent for treatment by requesting termination in writing.
Privacy Acknowledgement
(Required)
I agree to the privacy policy.
I understand that the patient’s health information is private and confidential. I understand that with this consent, I give permission for aspects of my/my child's private healthcare information to be shared with Axon Health Associates, LLC, as is necessary for services to be provided. I understand that Axon Health Associates, LLC may use and disclose the patient’s personal health information to help provide care to the patient, to handle billing and payment, and to take care of other health care operations. In general, there will be no other uses and disclosures of this information unless I permit it. I understand that sometimes the law may require the release of this information without my permission. By law, Axon Health Associates, LLC must report actual or suspected child or elder abuse to the appropriate authorities. In addition, Axon Health Associates, LLC is legally bound to take appropriate action if my child or I threaten anyone with violence, harm, or dangerous actions. I understand that there is a detailed document titled “Notice of Privacy Practices” that contains more information about the policies and practices protecting my privacy. I understand that I have the right to read the “Notice” before signing this acknowledgment. I am aware that a copy of this notice will be given to me upon my request or that it may be found at axonhealth.org. Axon Health Associates, LLC has established procedures which help meet patient obligations. These procedures may include other signature requirements, written acknowledgments, and authorizations; reasonable time frames for requesting information; charges for copies and non-routine information needs, etc. I will assist Axon Health Associates, LLC by following these procedures if I choose to exercise any of my rights described in the “Notice of Privacy Practices”. My signature below indicates that I have been given the chance to review a current copy of the “Notice of Privacy Practices”.
Financial Agreement
(Required)
I agree to the financial agreement.
I agree to pay in full, at the time of service, for all services rendered for myself or my child by Axon Health Associates, LLC, for any out-of-network services. I understand that there is a document available upon request or at axonhealth.org regarding the Fee Schedule and any financial obligations, and I have read and agree with the information in this document. For in-network services, I agree to pay for my copay at the time of service and understand that my insurance company will be billed for the remainder. I am aware that there is a document titled Insurance Tips that is available upon request or at axonhealth.org. This document will be helpful to understand what portion of the fees may be covered by my insurance plan. I understand that 24 hours notice of cancellation is required to avoid charges for missed appointments. I understand that in families where parents do not share the same household, payment for services is the responsibility of the parent who accompanies the child to the appointment.
I also understand and agree to pay for any services related to legal matters, including but not limited to depositions, attorney phone calls, and court testimony; these services may be a different pay rate.
I also understand and agree to pay for services including record retrieval, phone consultation, and email consultation as requested by the provider.
Consent to use Email Communications
(Required)
I agree to the email policy.
I hereby agree to sending to and receiving from Axon Health Associates, LLC email communications as part of comprehensive treatment for my child. I understand the risks of sending PHI through email even with encryption, and with this agreement I am accepting these risks to my child's PHI. I accept that Axon Health Associates, LLC shall not be held responsible for any exposure of email communications at my home or place of employment, depending on the location of my email address. I also understand that email communications can fail in their transmission, and I agree to contact Axon Health Associates, LLC if I have not obtained a response from my email communication within three business days. I also agree to never use email communications for emergency situations, and to call the office directly with any emergencies. I understand that I can terminate this agreement at any time by informing in writing. With my signature, I believe that the benefits of using email communications for my child's healthcare outweigh the security risks.
Patient History Questionnaire
Patient Name
(Required)
First
Last
Birth Date
(Required)
MM slash DD slash YYYY
Person Completing Questionnaire
(Required)
Relationship to Patient
(Required)
Purpose of Evaluation
What Are Your Primary Questions and Concerns?
Past Medical History
Have you ever been diagnosed with a medical condition?
(Required)
Yes
No
(please list)
(Required)
Have you ever been Hospitalized?
(Required)
Yes
No
When and for what condition?
(Required)
Have you ever had surgery?
(Required)
Yes
No
What was the surgery for?
(Required)
Are you currently taking any medications?
(Required)
Yes
No
List medication and dosage.
(Required)
Current Medical Concerns
Do you have any allergies to medications?
(Required)
Yes
No
List medication.
(Required)
Do you have any sleep concerns?
(Required)
Yes
No
Describe.
(Required)
Do you have any concerns with energy level?
(Required)
Yes
No
Describe.
(Required)
Do you experience headaches?
(Required)
Yes
No
With what frequency?
(Required)
Do you experience stomach pain?
(Required)
Yes
No
With what frequency?
(Required)
Past Mental Health Treatment
Please list any previous medications that you have been prescribed for mood, anxiety, or attention and any side effects you experienced.
(Required)
Have you ever received counseling or psychotherapy?
(Required)
Yes
No
When and what was the name of the therapist?
(Required)
Please list any prior mental health treatment programs, including substance abuse treatment, intensive outpatient or partial hospital programs, or psychiatric hospitalizations.
(Required)
Educational History
Highest Level of Education Achieved
(Required)
Some High School
High School Diploma
Some College
Associate's Degree
Bachelor's Degree
Additional Post-Secondary Education
Family History
Please list the persons presently living in your home.
Name
Gender
Birth Date
Relation to Patient
Add
Remove
During the past 12 months has your family experienced Death of a Family Member?
(Required)
Yes
No
During the past 12 months has your family experienced Marital Problems?
(Required)
Yes
No
During the past 12 months has your family experienced Serious Illness?
(Required)
Yes
No
During the past 12 months has your family experienced Unemployment?
(Required)
Yes
No
Other
(Required)
Yes
No
(please describe)
(Required)
Have any family members experienced Depression?
(Required)
Yes
No
Have any family members experienced Anxiety?
(Required)
Yes
No
Have any family members experienced ADHD?
(Required)
Yes
No
Have any family members experienced Autism?
(Required)
Yes
No
Have any family members experienced Bipolar disorder?
(Required)
Yes
No
Have any family members experienced Schizophrenia?
(Required)
Yes
No
Have any family members experienced Other mental health diagnoses?
(Required)
Yes
No
Have any family members experienced Heart or blood pressure problems?
(Required)
Yes
No
Describe
(Required)
Have any family members experienced Other medical problems?
(Required)
Yes
No
Describe
(Required)
Patient History Questionnaire
Child Name
(Required)
First
Last
Birth Date
(Required)
MM slash DD slash YYYY
Person Complete Questionnaire Name
(Required)
First
Last
Relationship to Patient
(Required)
Purpose of Evaluation
What are your questions or concerns regaurding your child?
(Required)
Pregnancy and Birth History
Is this your biological or adopted child?
(Required)
Biological
Adopted
If adopted, at what age did you adopt this child?
(Required)
Is the child aware of the adoption?
(Required)
Yes
No
Did you have any health problems during your pregnancy with this child?
(Required)
Yes
No
Please described nature of these complications such as infection, bed rest, high blood pressure
(Required)
Did you take any medications or use any drugs, alcohol or tobacco during pregnancy?
(Required)
Yes
No
Was your baby carried for a full nine months?
(Required)
Yes
No
Please indicate the length of pregnancy
(Required)
Did your baby need any special care after delivery?
(Required)
How much did your baby weigh at birth?
(Required)
Past Medical History
Has your child ever been hospitalized?
(Required)
Yes
No
Please describe the reason and what age this occurred.
(Required)
Has your child ever had any serious accidents or head injuries?
(Required)
Yes
No
Please describe and include your child’s age.
(Required)
Has your child had any serious or chronic illnesses (asthma, allergies, diabetes, etc)?
(Required)
Yes
No
Please describe and state if it has resolved.
(Required)
Has your child ever had a seizure?
(Required)
Yes
No
Please state at what age.
(Required)
Has your child ever had any tics (repetitive facial movements, throat clearing, sniffing, eye blinking, etc.)?
(Required)
Yes
No
Is your child taking any medications?
(Required)
Yes
No
Please list medication and dosage.
(Required)
Does your child have any allergies to medications?
(Required)
Yes
No
Please describe.
(Required)
Do you have concerns about your child’s eating habits?
(Required)
Yes
No
Please describe.
(Required)
Do you have concerns about your child’s sleep?
(Required)
Yes
No
Please describe.
(Required)
Does your child complain of pain more than once a week (headaches, stomachaches)?
(Required)
Yes
No
Developmental History
Did you have any concerns about your child’s development?
(Required)
Yes
No
Please explain.
(Required)
At what age did your child roll over?
(Required)
At what age did your child sit alone?
(Required)
At what age did your child crawl?
(Required)
At what age did your child walk?
(Required)
At what age did your child begin saying single words?
(Required)
At what age did your child begin combining words?
(Required)
Did your child have any developmental therapies (OT, PT, Speech)?
(Required)
Yes
No
What age?
(Required)
At what age did your child become toilet trained?
(Required)
Does your child currently have any daytime accidents?
(Required)
Yes
No
How often?
(Required)
Does your child have any nighttime accidents?
(Required)
Yes
No
How often?
(Required)
Past Mental Health Treatment
Please list any previous medications that your child has been prescribed for mood, anxiety, attention or behavior and any side effects he/she may have experienced.
(Required)
Has your child ever had any behavior therapy or counseling?
(Required)
Yes
No
Please include your child’s age at the time and the name of the therapist.
(Required)
Educational History
Please list the schools your child has attended:
(Required)
School Name
Dates Attended
Add
Remove
Please describe any educational services or resources that are provided to your child (IEP, 504 plan, special education services, etc.)
(Required)
Please describe any extracurricular activities in which your child participates.
(Required)
Please describe your child’s peer group and how he/she interacts with others.
(Required)
Family History
Parents are
(Required)
Married
Seperated
Divorced
Unmarried
Widowed
Date
(Required)
MM slash DD slash YYYY
Date
(Required)
MM slash DD slash YYYY
Date
(Required)
MM slash DD slash YYYY
Date
(Required)
MM slash DD slash YYYY
Describe custody arrangement and visitation.
(Required)
Please list the persons presently living in your home.
(Required)
Name
Gender
Birth Date
Relation to Child
Present or Highest Grade Completed
Add
Remove
Family members who no longer live in the home with the child.
(Required)
Name
Gender
Birth Date
Relation to Child
Present or Highest Grade Completed
Add
Remove
During the past 12 months has your family experienced
(Required)
Death of a Family Member
Serious Illness
Marital Problems
Unemployment
Other
Select All
Please Describe.
(Required)
Have any family members experienced Anxiety?
(Required)
Yes
No
Relationship to the child.
(Required)
Have any family members experienced Depression?
(Required)
Yes
No
Relationship to the child.
(Required)
Have any family members experienced ADHD?
(Required)
Yes
No
Relationship to the child.
(Required)
Have any family members experienced Autism?
(Required)
Yes
No
Relationship to the child.
(Required)
Have any family members experienced Bipolar disorder?
(Required)
Yes
No
Relationship to the child.
(Required)
Have any family members experienced Schizophrenia?
(Required)
Yes
No
Relationship to the child.
(Required)
Have any family members experienced other mental health diagnoses?
(Required)
Yes
No
Relationship to the child.
(Required)
Have any family members experienced Heart or blood pressure problems?
(Required)
Yes
No
Relationship to the child.
(Required)
Please describe.
(Required)
Have any family members experienced otther medical problems?
(Required)
Yes
No
Relationship to the child.
(Required)
Please describe.
(Required)
Person Completing Questionnaire
(Required)
Relationship to Child
(Required)
Date
MM slash DD slash YYYY
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