Child Information Form

Patient Name*
Other Preferred Name
Date of Birth*
Email*
Address*
Street Address City State ZIP Code
Phone*
Driver License No.
State
Educational Status
- Full Time Student
- Part Time Student
- N/A
If student, permanent/parents address
Name of School
Employers Name
Phone
Referring physician
Phone
Responsible Party
Phone
Address
Street Address City State ZIP Code
Date of Birth
Emergency Contact*
Emergency Contact Phone*
Referred By*
Do you plan on submitting claims to your insurance company for reimbursement?*
- YES
- NO
If yes, please note that you are responsible for requesting Superbills from your visits to allow you to file your own claim with your insurance company.
CONSENT TO TREATMENT
I HEREBY CONSENT TO EXAMINATION AND TREATMENT AS DEEMED NECESSARY BY PATRICIA A. HESS, M.D. I hereby request that payment of authorized benefits be made on my behalf and hereby assign the benefits payable for physician services to the physician if she chooses to accept the assignment. I hereby authorize Patricia A. Hess, M.D. PA to furnish Patient Health Information concerning my relevant medical history to any insurance company who will be paying the claim.
Signature*
Date*
MM slash DD slash YYYY
PRIVACY NOTICE
In accordance with the Health Insurance Portability and Accountability Act, patients of Patricia A. Hess M.D. PA are entitled to and afforded the rights to privacy regarding their health-related information as set forth under applicable law. Patricia A. Hess M.D. PA will strive to ensure that patient information is used only for purposes authorized by the patient and as otherwise required by law. Upon request, we can provide you with a complete copy of our Privacy Policies. Additionally, Patients have a right to review their medical records and furnish comments to their records during normal business hours, upon providing reasonable advance notice.
Signature*
Date*
MM slash DD slash YYYY
PRESCRIPTION HISTORY CONSENT
Agree that Patricia A. Hess, M.D. PA may request and use my prescription medication history from other healthcare providers and E-Forse (Florida's Prescription Drug Monitoring Program) for treatment purposes.
Signature*
Date*
MM slash DD slash YYYY
GOOD FAITH ESTIMATE
Dr. Patricia Hess, MD PA
Mailing Address: 2725 NW 38th St Gainesville FL 32605
Email: info@patriciahessmd.com
Phone: 352-224-5220
NPI: 1669669826
TIN: 273120009

PRIMARY SERVICE - Virtual Outpatient Visit
$315 - First Evaluation (99205-95) - 1 visit
$190 - First Follow Up or visits needing 40 minutes (99214-95) - 1-3 visits annually, depending on need
$125 - 20 Minute Follow Ups (99213-95) - 4-10 visits annually, depending on need
Office Policies
1. I certify that all of the information listed on this form is true and correct.
2. I understand that this is a fee for service, to be paid on the day of services rendered, a credit card must be obtained and kept on file for all charges.
3. If unable to keep your appointment, please give 24 hours’ notice of cancellation, otherwise a no show fee of $150 for new patients and $50 for established patients will be charged the day of missed appointment.
4. If this account is assigned to an attorney, collection agency, or small claims court, the prevailing party shall be entitled to reasonable attorney’s fees and cost of collection.
5. Any patient 10 minutes late for a scheduled appointment will be considered late and likely rescheduled and will be charged a $50 late fee unless there is another available appointment later the same day.
6. I understand that I am financially responsible for all charges, whether or not paid by said insurance. I hereby authorize said assignee to release all information to secure payment.
Signature*
Date*
MM slash DD slash YYYY
Signature of Parent or Guardian (If patient is a minor)*
Date*
MM slash DD slash YYYY
Present Problems
1) Describe as specifically as possible the problems which have led you to seek treatment or evaluation for your child.*
2) What do you believe to be the most important factors causing these problems?*
3) At what age did you first notice these problems?
4) Have there been any family changes or difficulties (new baby, family arguments, divorce) which may be related to these problems?
5) Has your child ever been treated for any behavioral and /or emotional problems?
- Yes
- No
6) Has your child experienced any of the following?
Makes up stories excessively
- Yes
- No
Age
How Often?
Talks to imaginary companions
- Yes
- No
Age
How Often?
Sees or hears things that do not exist
- Yes
- No
Age
How Often?
Runs away or sneaks out
- Yes
- No
Age
How Often?
Sets fires
- Yes
- No
Age
How Often?
Had problems with the law
- Yes
- No
Age
How Often?
Talked about or threatened to harm self
- Yes
- No
Age
How Often?
Has harmed self
- Yes
- No
Age
How Often?
Has excessive fears
- Yes
- No
Age
How Often?
Is hyperactive
- Yes
- No
Age
How Often?
Substance abuse
- Yes
- No
Age
How Often?
Sadness or depression
- Yes
- No
Age
How Often?
Aggression towards others
- Yes
- No
Age
How Often?
Temper tantrums
- Yes
- No
Age
How Often?
Overanxious
- Yes
- No
Age
How Often?
Sleeping problems
- Yes
- No
Age
How Often?
Bad dreams
- Yes
- No
Age
How Often?
Lost interest in activities
- Yes
- No
Age
How Often?
Impulsive acts without thinking
- Yes
- No
Age
How Often?
Sudden behavior or personality change
- Yes
- No
Age
How Often?
Inappropriate sexual behavior
- Yes
- No
Age
How Often?
Poor appetite
- Yes
- No
Age
How Often?
Problems with authority
- Yes
- No
Age
How Often?
Takes risks
- Yes
- No
Age
How Often?
Bad companions
- Yes
- No
Age
How Often?
Destruction of property
- Yes
- No
Age
How Often?
7) Has your child previously been evaluated with psychological tests, e.g. intelligence testing and/or personality evaluation?
- Yes
- No
If so, please provide details:
School Information
1) What schools has your child attended?
Name of School
City/State
Grade
Special Education
Name of School
City/State
Grade
Special Education
Name of School
City/State
Grade
Special Education
Name of School
City/State
Grade
Special Education
Name of School
City/State
Grade
Special Education
Name of School
City/State
Grade
Special Education
2) Has your child ever repeated a grade?
- Yes
- No
Grade Repeated
Reason
Grade Repeated
Reason
3) Estimate grade average for each year of school:
K
1
2
3
4
5
6
7
8
9
10
11
4) Has your child experienced any of the following problems in school?
Getting along with other children
- Yes
- No
Grade
How Often?
Short attention span
- Yes
- No
Grade
How Often?
Overactive
- Yes
- No
Grade
How Often?
Reading
- Yes
- No
Grade
How Often?
Writing letters or numbers
- Yes
- No
Grade
How Often?
Spelling
- Yes
- No
Grade
How Often?
Finishing work in class
- Yes
- No
Grade
How Often?
Homework
- Yes
- No
Grade
How Often?
Frequent absences due to illness
- Yes
- No
Grade
How Often?
Skipping school
- Yes
- No
Grade
How often?
Suspension from school
- Yes
- No
Grade
How often?
Behavior/conduct problems
- Yes
- No
Grade
How often?
Other
- Yes
- No
Grade
How often?
6) Please rate your child’s effort in school:
- Above Average
- High
- Average
- Low
7) What are your child’s usual conduct grades?
K-2
3-5
6-8
9-12
8) Please estimate your child’s intelligence level:
- Above Average
- Average
- Below Average
Medical History
Name of child’s pediatrician or family doctor:
Phone
1 ) Does your child have any physical or medical problems or handicaps? (e.g., diabetes, asthma, heart condition)
- Yes
- No
If yes, please explain
2) Is your child taking any medications?*
- Yes
- No
If yes, please list below
Medication
Who Prescribed
How Long?
Medication
Who Prescribed
How Long?
Medication
Who Prescribed
How Long?
3) Does your child have any allergies?*
- Yes
- No
If Yes, please explain
Allergy
Reaction
Allergy
Reaction
Allergy
Reaction
4) Has your child experienced any of the following?
Soiling or lack of bowel control
- Yes
- No
Date
MM slash DD slash YYYY
Wetting or lack of bladder control
- Yes
- No
Date
MM slash DD slash YYYY
Any urinary infections
- Yes
- No
Date
MM slash DD slash YYYY
Convulsions
- Yes
- No
Date
MM slash DD slash YYYY
Loss of consciousness
- Yes
- No
Date
MM slash DD slash YYYY
Eye examination (give date)
- Yes
- No
Date
MM slash DD slash YYYY
Ear examination (give date)
- Yes
- No
Date
MM slash DD slash YYYY
Corrected vision
- Yes
- No
Date
MM slash DD slash YYYY
Corrected hearing
- Yes
- No
Date
MM slash DD slash YYYY
Persistent headaches requiring treatment
- Yes
- No
Date
MM slash DD slash YYYY
Abnormal weight loss or gain
- Yes
- No
Date
MM slash DD slash YYYY
Frequent colds/respiratory conditions
- Yes
- No
Date
MM slash DD slash YYYY
Any known heart condition
- Yes
- No
Date
MM slash DD slash YYYY
Unusual muscular weakness
- Yes
- No
Date
MM slash DD slash YYYY
Rocking, head banging
- Yes
- No
Date
MM slash DD slash YYYY
Thumbsucking
- Yes
- No
Date
MM slash DD slash YYYY
Preoccupation with physical complaints
- Yes
- No
Date
MM slash DD slash YYYY
If there were any difficulties, please explain:
5) Which childhood illnesses or diseases has your child had and at what age?
illness
Age at time
illness
Age at time
illness
Age at time
6) Has your child been injured in any falls or accidents?
- Yes
- No
If yes, please explain:
Developmental Information:
1) Were there any physical or emotional difficulties during pregnancy with this child?
- Yes
- No
If yes, please explain:
2) Was this child born premature?
- Yes
- No
If yes, number of weeks early?
3) Were there any of the following complaints?
- Long labor
- Forceps delivery
- Breech birth
- Eclampsia
- Caesarian Section
- Other
If other, please explain:
Did mother take any medications during pregnancy?
- Yes
- No
If yes, please list:
4) Were there any immediate complications following delivery?
- Yes
- No
If yes, please explain:
5) Average delays in:
Walked
- Yes
- No
Talked (words)
- Yes
- No
Talked (sentences)
- Yes
- No
Toilet trained
- Yes
- No
Weaned
- Yes
- No
Began to menstruate
- Yes
- No
Developed secondary sex characteristics
- Yes
- No
Personal Information:
1) What are your child’s interests, strengths and assets?
2) What does your child spend most of his/her free time doing?
Nutritional Information:
1) Has your child had an eating problem?
- Yes
- No
If yes, please explain:
2) Has your child been on a special diet?
- Yes
- No
If yes, please explain:
Family History
1) Does the child live with both parents?
- Yes
- No
If no, who does the child live with?
2) Name of mother:
Age
3) Name of father:
Age
4) Are there any of the following: Step Parents
- Yes
- No
If yes please list names and relationship to child:
Adoptive parents:
- Yes
- No
If yes please list names and relationship to child:
Legal Guardians:
- Yes
- No
If yes please list names and relationship to child:
5) Please list all natural and half siblings, their sex and age:
6) Who else lives in the home with the child (e.g., stepsiblings, grandparents, other relatives, etc.)
7) Has your child ever lived with anyone else for any period?
- Yes
- No
If yes, please explain:
When:
With whom:
Why:
8) Have any other children in the family had problems?
- Yes
- No
If yes, please explain:
9) Has anyone in the immediate family (mother, father, grandparents, aunts/uncles, siblings, etc.) ever had any of the following problems?
Epilepsy
- Yes
- No
Relationship to child
Diabetes
- Yes
- No
Relationship to child
Mental Illness requiring hospitalization
- Yes
- No
Relationship to child
Nervous breakdown
- Yes
- No
Relationship to child
Outpatient treatment for emotional problems
- Yes
- No
Relationship to child
Allergies
- Yes
- No
Relationship to child
Excessive use of alcohol
- Yes
- No
Relationship to child
Excessive use of drugs or medication
- Yes
- No
Relationship to child
Suicide
- Yes
- No
Relationship to child
Serious legal difficulties (prison sentence)
- Yes
- No
Relationship to child
10) Is there anything else you feel we need to know about your child or the family in order to provide help to him/her?
(I, We) understand that this information will be used in the evaluation of (my, our) child and will be included in the child’s record. Our commitment to your privacy:Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding your child and the treatment and services we provide to him/her. We are required by law to maintain the confidentiality of health information that identifies you and your child. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your child’s PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
Signature of Parent or Legal Guardian*
Date*
MM slash DD slash YYYY
Signature of Parent or Legal Guardian*
Date*
MM slash DD slash YYYY
CLICK HERE TO PRINT THIS FORM BEFORE SUBMITTING

Child Information Form

CONSENT TO TREATMENT

PRIVACY NOTICE

PRESCRIPTION HISTORY CONSENT

GOOD FAITH ESTIMATE

Office Policies

Present Problems

School Information

Medical History

Developmental Information:

Personal Information:

Nutritional Information:

Family History