Priority Pediatrics PC

Available Forms

1. NEW Patient Online Intake History Form for Dr. T 2. ESTABLISHED Patient Online Interim History Form for Dr. T 3. Lead Exposure Risk Questionnaire for parent to complete for Dr. T 4. Request to Transfer Medical Records to Priority Pediatrics 5. Pediatric Symptom Checklist for PARENTS of 11-18 Year Olds to Complete for Dr. T 6. Pediatric Symptom Checklist for YOUTH ages 11-18 Years to Complete for Dr. T 7. Adolescent Mood Questionnaire for the Teen to complete for Dr. T 8 Side Effect Patient Check List 9. Tuberculosis (TB) Exposure Risk Questionnaire to complete for Dr. T 10. Pediatric Sleep Questionnaire / PSQ for parent to complete for Dr. T

2. ESTABLISHED Patient Online Interim History Form for Dr. T

If you do not already have an Updox ID & password, please register on my Updox Portal BEFORE starting this questionnaire so that your work can be saved, retrieved & continued. Once you log onto my Updox Portal with an ID & password, you will be able to save & retrieve past sent forms and resend if needed. Also do NOT use your BACK Button or REFRESH, or you will lose all your Form answers and need to start over. You can call any incorrect or additional information to my attention at the end of the form. Thank you. Dr. T

You are welcome to answer N/A on any required question that you feel does not need an answer, then move on to the next item.

Today's date *

Name of Person completing form: *

Relationship to Patient: *

I agree to receive patient appointment reminders and messages via email, SMS mobile texting or voice phone calls to be in compliance with the Telephone Consumer Protection Act (TCPA). *

Yes

I need more information and wish to talk with you.

My Spouse/Partner agrees to receive patient appointment reminders and messages via email, SMS mobile texting or voice phone calls to be in compliance with the Telephone Consumer Protection Act (TCPA). *

Yes

Not applicable

I need more information and wish to talk with you.

Patient's Name (First Middle, Last) *

Patient's Date of Birth *

The preferred name your child is called by: *

Patient Contact Information (if Adolescent)

What is your child/adolescent's current cell phone number? *

What is your child/adolescent's current email address? *

Have you discussed Cyber-bullying & sexting with your youth? *

Yes

Don't intend to

Don't know how to

Don't know what to say

I would like info on this topic

Have you asked your child or adolescent if he/she has ever been a victim of bullying or cyberbullying? *

Yes

N/A

I would like to know more about this area of concern

What is your child's home phone #? *

Mother's Updated Contact Information

Mother's Current Address (Street, City, State, Zip & county *

Mother's preferred phone number: *

Mother's preferred email address? *

Spouse/Partner's Current Contact Information

Spouse/Partner's Name (First, Middle, Last) *

Spouse/Partner's Current Address (Street, City, State, Zip & County *

Spouse/Partner's preferred phone number? *

Spouse/Partner's preferred email address? *

Emergency Contact Information

Who is the nearest relative (other than spouse/partner) in case emergency contact is needed; what is the relationship to the child & what is the preferred phone number? *

Patient Current Insurance Information

Please fax (678-806-0900) or mail (6300 Powers Ferry Road, Suite 600, #202, Atlanta, GA 30339) a legible copy of the front & back of the patient's insurance card. This will facilitate preparation of your statement of services for your insurance claim for your reimbursement for our services.

Please Update Your Child's Personal Past Medical History (not the relatives)

Please Update any Major Events/Hospitalizations/Surgeries with dates since you last completed this form.

Please indicate if child has had any of these illnesses or conditions since you last completed this form: *

And for your child over age 10 yrs, please indicate if:

Has your child ever passed out or nearly passed out during or after exercise?

Has your child ever had discomfort, pain, tightness or pressure in his/her chest during exercise?

Does your child's heart ever race, flutter in the chest, or skip beats (irregular beats) during exercise?

Has a doctor ever told your child that she/he has any heart problem?

Has a doctor ever requested a test for your child's heart? For example, electrocardiography (ECG/EKG) or echocardiography (a heart ultrasound)?

Does your child get light-headed or feel shorter of breath than expected during exercise?

Has your child ever had a seizure or convulsion?

Has your child ever had a stress fracture or an injury to a bone, muscle, ligament, joint, or tendon that caused him/her to miss a practice or game?

Does your child have a bone, muscle, ligament, or joint injury that bothers her/him?

Please elaborate on any of the above if needed.

Is the child/adolescent currently receiving allergy shots? *

Yes

Don't know

Has in the past, but not now

Do you have any current concerns about the child's hearing, speech, language use or developmental or academic delay? *

Yes

Maybe

When was the child/adolescent's most recent Vision & Hearing Screening or Testing? *

Are there any other recent past illnesses or conditions that you think your child's doctor would want to know about?

Yes

I prefer to discuss face-to-face with the doctor at a visit or by phone

Please elaborate, if needed, on any of the above.

Please Update any Operations/Procedures/Hospitalizations of your child since you last completed this form (enter dates)

Has your child/adolescent had any of these procedures since you last completed this form? *

Please elaborate on any of the above as needed. Provide dates, Hospital names & locations, and Physician Names if known.

Known or Suspected Allergies

Are there Allergies to ANY medications? *

Yes

Uncertain

Please elaborate on dates and the kind of reaction experienced and the care received.

Are there any Allergies to Foods or Insects? *

Yes

Uncertain

Please elaborate if needed:

Please Update Your Child/Adolescent's Biologic Family Medical History since you last completed this form ( your child's biologic relatives: parents, grandparents, great-grandparents, aunts, uncles, first cousins)

Has any biologic family member or biologic relative died of a heart problem, or had an unexpected or unexplained death before age 55 years (including drowning, unexplained car accident, or sudden infant death syndrome/crib death? *

Yes

Maybe

Don't know

Does anyone on either side of the biologic family have hypertrophic cardiomyopathy, Marfan syndrome, arrythmogenic right ventricular cardiomyopathy, long QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia? *

Yes

I am not familiar with these conditions

Don't know

Has anyone on either side of the biologic family (parent, grandparent, aunt or uncle, or sibling) had myocardial infarction (MI); angina; stroke; or coronary artery bypass graft/stent/angioplasty before age 55 years in males and before 65 years in females? *

Yes

Don't know

Has anyone in the biologic family had unexplained fainting, unexplained seizures, or drowning or near drowning? *

Yes

Maybe

Don't know

Have any of your child's close biologic relatives (your child's grandparents, siblings, aunts, uncles, 1st cousins) had any of these conditions? *

Please elaborate as needed if you have indicated a positive history in the questions above?

Have any of your family members -- aunts, uncles, cousins, or parents -- had glasses before the age of 5 years? *

Yes

Don't know

Have any of these family members had an eye that turns in or turns out or worn a patch? *

Yes

don't know

Have any members of your biological family died or become chronically sick at an early age since you last completed this form? *

Yes

Don't know

Do you have any (some) concerns about diseases or conditions that run in the family? *

Yes

Don't know

Are there any other risk factors or non-medical conditions that run in your family? *

Yes

Maybe

Don't know

You may elaborate further here concerning the above if you wish.

Your Family/Home Environment

Are there any smokers in your home or in the homes of others where your child spends time? *

Is there an unlocked gun in your home or another house where your child spends time? *

Yes

Don't know

Would you like information about how to securely store a gun in a home? *

Yes

I know how to securely store a weapon and how to ask others to do the same

Has there been a marital or partner separation, divorce, or death in the immediate family since the last time you completed a form like this? *

Yes

Don't know

Has there been a remarriage or a re-partnering? *

Current Nutritional Concerns

Do you have concerns about your child's nutrition? *

Yes

I would like to speak with doctor about this area.

Does your child limit, restrict or avoid any of the basic food groups: Dairy, Meats & Eggs, Fruits, Veggies, Breads & Grains, etc? *

Does your child/adolescent take any vitamins &/or nutritional supplements? *

Yes

Don't know

If Yes, please list Product names & quantity & dosing information.

If your child/adolescent is using a Sport Supplement of any kind, please note Product Name & Quantity & Frequency of Use:

Significant Recent Diagnoses

Please elaborate on any significant Health conditions you feel your child has had since you last completed a form like this. (names, dates, treatments, treating doctors, etc)

Please list the names of any specialists who have treated your child since you last completed a form like this. (Condition, dates, etc)

Please list recent & current significant medications your child has/is taking since you last completed a form like this. (names, dates, treating doctors)

Do you have any concerns about past or future immunizations that your child might need? *

No concerns

Yes, I have concerns

I would like to talk with doctor about this area of health.

Your immunization concerns?

Use this space if you would like to share your immunization concerns with Dr. T.

Your Current Concerns?

Do you have any current concerns, needs or questions about your child's or adolescent's physical, emotional, social or sexual/gender health that you would like to discuss with Dr. T? *

Yes

Not sure

You may elaborate here, if you wish, about your concerns or needs regarding your child/adolescent.

Have any members of your biological family died or become chronically sick at an early age since you last completed a form like this?

Yes

Don't know

Thank you for taking the time to update & complete your child's medical history form for Dr.T and Priority Pediatrics PC. You can transmit this form electronically & securely via Updox, or you may print it and mail it to us or fax it to the practice @ 678-806-0900. This information will become part of your child's confidential Electronic Health Record.

If you logged in to Updox with an ID & password, this form is saved when you click SEND. You CAN resend the form if you need to if you have registered on my Updox Portal. You will need to go to the Messages Tab and then choose the Sent tab. Your previously sent form should be listed there. You will need to click on the form, then select "Reply" at the top. This will resend the form to Dr. T.

Although you can not use your BACK button or REFRESH this form or alter, amend or change a form you have previously sent, you can add a message here as to what information you would like to change if you were able to resend the original or correct your answers on this form.

New Field89

* Required field