ONSLOW PEDIATRIC ASSOCIATES, P. A.
PATIENT INFORMATION
Patient's Full Name:(Last)(First)Child's Date of Birth:(Middle)Child's Gender: Male or Female

SSN# :

Home Address: _______________________________________________________________________________________(Street)Primary Phone Number:
Emergency Contact Number:(((City)))-(State)(Zip Code)Is this a cellphone: Y or N
Emergency Contact Name:

Please circle the best answer to the following questions:
Language of child: English / Spanish / Japanese / Tagalog / Other _________________________
Ethnicity of child: Unknown / Hispanic or Latino / Not Hispanic or Latino / Decline to Specify
Race of child: American Indian or Alaskan Native/ Asian/ Black or African-American/ Hawaiian Native or Pacific Islander/ White/ Declined to Specify

Please circle the preferred contact method for each of the following:
Medical Issues: Primary Phone / Cell Phone / Text to Cell Phone / EmailAppointment Reminders: Primary Phone / Cell Phone / Text to Cell Phone / EmailAppointment Recalls: Primary Phone / Cell Phone / Text to Cell Phone / Email

Mother/Guardian's Full Name: _______________________________________
Date of Birth: __________________
Email: _____________________________________
Phone Number: ()Home Address: _______________________________________________________________________________________(Street)(City)(State)(Zip Code)

Language: English / Spanish / Other ________________________
Phone Number: ()-SSN#:
Employer:

Father/Guardian's Full Name: _______________________________________
Date of Birth: __________________
Email: ____________________________________
Phone Number: ()Home Address: ___________________________________________________________________________________(Street)(City)(State)(Zip Code)

Language: English / Spanish / Other ________________________

SSN#:
Employer:

Phone Number: (Emergency Contact Name:

Phone Number:)()

INSURANCE INFORMATION
Primary Insurance Name:
Policy #: _______________________________________________________
Group #:
Subscriber Name: _______________________________________________ Date of Birth: __________________
Relationship to Patient: ________________________________________
Employer: _____________________________
Home Address: ___________________________________________________________________________________(Street)(City)(State)(Zip Code)

Secondary Insurance Name:
Policy #: _______________________________________________________
Group #:
Subscriber Name: _______________________________________________ Date of Birth: __________________
Relationship to Patient: ___________________________________ Employer: _____________________________
Home Address: ___________________________________________________________________________________(Street)(City)(State)(Zip Code)
1/27/2017

ONSLOW PEDIATRIC ASSOCIATES, P. A.
BIRTH HISTORY
Patient's Name: ____________________________________________________(Last)

Where was the patient born? ______________________
Was a NICU stay required?

YD.O.B ____________(First)NHow many weeks at birth? ______________

Explain reason for stay: __________________________________

During pregnancy, did mother use any of the following: Tobacco / Drink Alcohol / Drugs or Medications
If yes, describe what and how long any of the above was used: ___________________________________

PAST MEDICAL HISTORY
Has the Patient ever had problems with or been diagnosed with any of the following:
Circle correct answer and explain if needed:( DK = Don't Know)

Any Birth Defects
Genetic Conditions

YYNN

DK
DKExplain
ExplainThyroid or other Endocrine Disorders
Diabetes
Bladder/ Kidney Infections or otherYYNN

DK
DK

Explain
Explain

Urologic Problems
CancerFrequent Infections / Immune Disorders

YYYNNNDK
DK
DK

Explain
Explain
Explain

GI Disorders
Mental Health Disorders
Neurologic Disorders: ADHD /Seizures / Developmental Delays
Heart Conditions or Heart Murmur
Anemia or Bleeding Disorder
Blood Transfusion
Orthopedic Problems
Serious Injuries or Accidents
Surgeries
Hospitalizations
Nasal Allergies or other Allergies
Respiratory Conditions:Asthma, Bronchitis, Pneumonia
Chronic or Recurrent Skin Problems
Frequent Ear Infections or Sinus Infections
Pharyngitis/Tonsillitis
Frequent Abdominal Pain
Constipation requiring doctor visits
Bed-wetting (after 5 years of age)
Eating Disorders
Special Diet
Nutrient Deficiency
Hearing Problems
Eye Conditions/ Corrective Lenses
Frequent Headaches
If Female, have Menstrual Periods Started
If Female, any problems with Periods
Use of Alcohol or Drugs
Other Significant Problems

Y
Y

N
N

DK
DK

Explain
Explain

YYY
Y
YY
Y
Y
YN
N
N
N
N
N
N
N
N

DK
DK
DK
DK
DK
DK
DK
DK
DK

Explain
Explain
Explain
Explain
Explain
Explain
Explain
Explain
Explain

YY
Y
YY
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N

DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK
DK

Explain
Explain
Explain
Explain
Explain
Explain
Explain
Explain
Explain
Explain
Explain
Explain
Explain
Explain
ExplainExplain
Explain

1/27/2017

ONSLOW PEDIATRIC ASSOCIATES, P. A.
SOCIAL HISTORY
Patient's Name: _________________________________________________________(Last)

D.O.B _____________(First)Please list all those living in the child's home:
Relationshipto childName

Birth Date

Health Problems

What is the child's living situation if not with both biological parents?
Joint Custody/Single Custody please explain: ____________________________________________
Lives with Adoptive Parents
YN
Lives with Foster Family
YN
Lives with other Relatives
YN Explain: ______________________________
Any Pets in the home?
YN
Any Smokers in the home?
YN
Any Guns in the home?
YN
If yes, are they locked up and kept separate from the ammunition?
YN

FAMILY MEDICAL HISTORY
Have any family members had the following:
Circle correct answer and state the relationship to patient:

Nasal Allergies or Other Allergies
Asthma/Lung Disease
Heart Disease
High Blood Pressure
High Cholesterol
Diabetes or Other Endocrine Problems
CancerAnemiaBleeding Disorders
Mental Retardation or Developmental
Disorders
Neurologic Disorders including ADHD
Liver Disease
GI Conditions
Kidney Disease
Bed-wetting (after 10 years old)
Hearing Impairment
Vision Impairment or Eye Conditions
AIDS/HIV or Recurrent Infections
Alcohol abuse
Drug Abuse
Mental Illness
Tuberculosis
Any additional family conditions

Mother, Father, Maternal Grandparents, Paternal Grandparents, Aunt, Uncle

Y
Y
Y
Y
Y
Y
Y
Y
Y

N
N
N
N
N
N
N
N
N

WHO:
WHO:
WHO:
WHO:
WHO:
WHO:
WHO:
WHO:
WHO:

Y
Y
Y
Y
Y
Y
Y
YYYY
Y
Y
Y

N
N
N
N
N
N
N
N
N
N
N
N
N
N

WHO:
WHO:
WHO:
WHO:
WHO:
WHO:
WHO:
WHO:
WHO:
WHO:
WHO:
WHO:
WHO:
WHO:

1/27/2017