Child Information FormPatient Name*Other Preferred NameDate of Birth*Email* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Driver License No. AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Educational Status Full Time Student Part Time Student N/AIf student, permanent/parents addressName of SchoolEmployers NamePhoneReferring physicianPhoneResponsible PartyPhoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of BirthEmergency 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 TREATMENTI 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 NOTICEIn 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 CONSENTAgree 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 ESTIMATEDr. 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 $350 - First Evaluation with Dr. Patricia Hess, MD (99205-95) - 1 visit. Payment will be collected 1 day before visit $190 - First Follow Up or visits needing 40 minutes (99214-95) - 1-3 visits annually, depending on need. Payment collected the morning of the appointment. $125 - 20 Minute Follow Ups (99213-95) - 4-10 visits annually, depending on need. Payment collected the morning of the appointment.Office PoliciesI certify that all of the information listed on this form is true and correct.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.No shows and all cancellations with less than 24 hours notice will result in the following No Show Fees:- First Evaluation - Full fee will be collected- 40 Minute Appointments - $75 the first time and then full fee for all subsequent visits- 20 Minute Appointments – $50 the first time and then full fee for all subsequent visitsAny patient 10 minutes late for a scheduled appointment will be considered a No Show resulting with the No Show Fee listed above and will need to be rescheduled.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.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 Problems1) 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 No6) Has your child experienced any of the following?Makes up stories excessively Yes NoAgeHow Often?Talks to imaginary companions Yes NoAgeHow Often?Sees or hears things that do not exist Yes NoAgeHow Often?Runs away or sneaks out Yes NoAgeHow Often?Sets fires Yes NoAgeHow Often?Had problems with the law Yes NoAgeHow Often?Talked about or threatened to harm self Yes NoAgeHow Often?Has harmed self Yes NoAgeHow Often?Has excessive fears Yes NoAgeHow Often?Is hyperactive Yes NoAgeHow Often?Substance abuse Yes NoAgeHow Often?Sadness or depression Yes NoAgeHow Often?Aggression towards others Yes NoAgeHow Often?Temper tantrums Yes NoAgeHow Often?Overanxious Yes NoAgeHow Often?Sleeping problems Yes NoAgeHow Often?Bad dreams Yes NoAgeHow Often?Lost interest in activities Yes NoAgeHow Often?Impulsive acts without thinking Yes NoAgeHow Often?Sudden behavior or personality change Yes NoAgeHow Often?Inappropriate sexual behavior Yes NoAgeHow Often?Poor appetite Yes NoAgeHow Often?Problems with authority Yes NoAgeHow Often?Takes risks Yes NoAgeHow Often?Bad companions Yes NoAgeHow Often?Destruction of property Yes NoAgeHow Often?7) Has your child previously been evaluated with psychological tests, e.g. intelligence testing and/or personality evaluation? Yes NoIf so, please provide details:School Information1) What schools has your child attended?Name of SchoolCity/StateGradeSpecial EducationName of SchoolCity/StateGradeSpecial EducationName of SchoolCity/StateGradeSpecial EducationName of SchoolCity/StateGradeSpecial EducationName of SchoolCity/StateGradeSpecial EducationName of SchoolCity/StateGradeSpecial Education2) Has your child ever repeated a grade? Yes NoGrade RepeatedReasonGrade RepeatedReason3) Estimate grade average for each year of school:K12345678910114) Has your child experienced any of the following problems in school?Getting along with other children Yes NoGradeHow Often?Short attention span Yes NoGradeHow Often?Overactive Yes NoGradeHow Often?Reading Yes NoGradeHow Often?Writing letters or numbers Yes NoGradeHow Often?Spelling Yes NoGradeHow Often?Finishing work in class Yes NoGradeHow Often?Homework Yes NoGradeHow Often?Frequent absences due to illness Yes NoGradeHow Often?Skipping school Yes NoGradeHow often?Suspension from school Yes NoGradeHow often?Behavior/conduct problems Yes NoGradeHow often?Other Yes NoGradeHow often?6) Please rate your child’s effort in school: Above Average High Average Low7) What are your child’s usual conduct grades?K-23-56-89-128) Please estimate your child’s intelligence level: Above Average Average Below AverageMedical HistoryName of child’s pediatrician or family doctor:Phone1 ) Does your child have any physical or medical problems or handicaps? (e.g., diabetes, asthma, heart condition) Yes NoIf yes, please explain2) Is your child taking any medications?* Yes NoIf yes, please list belowMedicationWho PrescribedHow Long?MedicationWho PrescribedHow Long?MedicationWho PrescribedHow Long?3) Does your child have any allergies?* Yes NoIf Yes, please explainAllergyReactionAllergyReactionAllergyReaction4) Has your child experienced any of the following?Soiling or lack of bowel control Yes NoDate MM slash DD slash YYYY Wetting or lack of bladder control Yes NoDate MM slash DD slash YYYY Any urinary infections Yes NoDate MM slash DD slash YYYY Convulsions Yes NoDate MM slash DD slash YYYY Loss of consciousness Yes NoDate MM slash DD slash YYYY Eye examination (give date) Yes NoDate MM slash DD slash YYYY Ear examination (give date) Yes NoDate MM slash DD slash YYYY Corrected vision Yes NoDate MM slash DD slash YYYY Corrected hearing Yes NoDate MM slash DD slash YYYY Persistent headaches requiring treatment Yes NoDate MM slash DD slash YYYY Abnormal weight loss or gain Yes NoDate MM slash DD slash YYYY Frequent colds/respiratory conditions Yes NoDate MM slash DD slash YYYY Any known heart condition Yes NoDate MM slash DD slash YYYY Unusual muscular weakness Yes NoDate MM slash DD slash YYYY Rocking, head banging Yes NoDate MM slash DD slash YYYY Thumbsucking Yes NoDate MM slash DD slash YYYY Preoccupation with physical complaints Yes NoDate 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?illnessAge at timeillnessAge at timeillnessAge at time6) Has your child been injured in any falls or accidents? Yes NoIf yes, please explain:Developmental Information:1) Were there any physical or emotional difficulties during pregnancy with this child? Yes NoIf yes, please explain:2) Was this child born premature? Yes NoIf yes, number of weeks early?3) Were there any of the following complaints? Long labor Forceps delivery Breech birth Eclampsia Caesarian Section OtherIf other, please explain:Did mother take any medications during pregnancy? Yes NoIf yes, please list:4) Were there any immediate complications following delivery? Yes NoIf yes, please explain:5) Average delays in:Walked Yes NoTalked (words) Yes NoTalked (sentences) Yes NoToilet trained Yes NoWeaned Yes NoBegan to menstruate Yes NoDeveloped secondary sex characteristics Yes NoPersonal 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 NoIf yes, please explain:2) Has your child been on a special diet? Yes NoIf yes, please explain:Family History1) Does the child live with both parents? Yes NoIf no, who does the child live with?2) Name of mother:Age3) Name of father:Age4) Are there any of the following: Step Parents Yes NoIf yes please list names and relationship to child:Adoptive parents: Yes NoIf yes please list names and relationship to child:Legal Guardians: Yes NoIf 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 NoIf yes, please explain:When:With whom:Why:8) Have any other children in the family had problems? Yes NoIf 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 NoRelationship to childDiabetes Yes NoRelationship to childMental Illness requiring hospitalization Yes NoRelationship to childNervous breakdown Yes NoRelationship to childOutpatient treatment for emotional problems Yes NoRelationship to childAllergies Yes NoRelationship to childExcessive use of alcohol Yes NoRelationship to childExcessive use of drugs or medication Yes NoRelationship to childSuicide Yes NoRelationship to childSerious legal difficulties (prison sentence) Yes NoRelationship to child10) 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