Please register on my Updox Portal BEFORE starting this questionnaire so that your work can be saved and continued. Once you are registered on the Portal, you will be able to 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.
Patient Contact Information (if Adolescent)
Mother's Contact Information:
Spouse or Partner's Contact information:
Emergency Contact Information:
Patient Insurance Information
Please fax (678-806-0900) or mail (#202, 6300 Powers Ferry Road, Suite 600, Atlanta, GA 30339) a legible copy of the front & back of the patient's insurance card. This will facilitate preparation of your insurance claim for your reimbursement for our medical services.
Your Child's Personal Past Medical History (not the relatives):
Major Events/ Hospitalizations/ Surgeries & Dates:
Operations/ Procedures/ Hospitalizations of child (Enter Dates)
Known or Suspected Allergies:
Family Medical History (child's biologic relatives: parents, grandparents, great-grandparents, aunts, uncles, first cousins)
Please answer these Health Risk Family History Questions:
Your Family's Social History:
Nutritional History & Concerns:
Child's Developmental History:
History of Significant Past Diagnoses (names & dates):
Use this space if you would like to share your immunization concerns with the doctor.
Thank you for taking the time to 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.
This form is saved by UpDox and 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.