Release of Health Information/Records
Welcome to Lighthouse Pediatrics! We are pleased that you have chosen to establish your child in this special practice. In order for us to use your time with the doctor wisely, could you please take a few moments to complete the following information about your child?
Name of Child:
Date of Birth:
Does your child have any ongoing medical problems?:
Yes No
If yes, please list
Specialist(s), if any:
Does your child have any past medical problems which he/she's outgrown?:
Yes No
Has your child spent the night in the hospital?
Yes No
Any surgeries?
Yes No
Please list with approximate date(s):
Is your child on medications (include prescription and over-the-counter)?
Yes No
If yes, please list along with doses:
Pharmacy:
Does your child have any allergies?
Yes No
Please list:
Please choose any of the conditions that run in your family (parents, aunts/uncles, grandparents and siblings) and what family member is affected.
ADD/ADHD
Allergies
Arthritis
Asthma
Cancer
Cardiac Disease
Crohn's oor Ulcerative Colitis
Diabetes
Drug/Alcohol Abuse
High blood pressure
High cholesterol
Migraines
Prolonged QT syndrome
Seizure
Sickle cell
Sudden Unexplained death
Thyroid Disorders
Vision/Hearing disorders
Other
Who lives in the house with your child?
Do you own any pets?
Yes No
If yes, type of pet:
Are there any smokers in the home?
Yes No Inside Outside
Do you have any water near your home?
Yes No
If yes, please choose
Private Pool Community Pool Lake Canal Ocean
If you have a private pool, do you have a pool fence?
Yes No
If your child is 4 years or older, does he/she know how to swim?
Yes No
Does you child attend a daycare or school?
Yes No
Name of the daycare or school:
Grade/year:
Does your child have any special needs in school or daycare?
Yes No
If so, please list:
Do you have any questions/concerns you want to address today?
Do you have any prayer requests?