KIDSWELLNESS PEDIATRICS

Eric N. Rydland, M.D.

 1921 Commonwealth Dr.

Charlottesville, VA 22901

434-984 KIDS (5437), Fax: 434-984-5439

DrRydland@kidswellness.com

www.kidswellness.com

PATIENT INFORMATION FORM

Please take a few minutes to complete the following information so that we may better provide

for your family’s medical needs. Please complete all pages and answer all questions as much as possible.

Due to the nature of our work we do not bill insurance.

All visits are charged based upon time and complexity of the medical condition(s) and discussion. You will be supplied with the necessary paperwork to process your own insurance claim upon payment.

All appointments not cancelled at least 48 hours in advance will be charged a non-cancellation fee.

DATE:

PATIENT’S NAME:_____________________________________________________

DATE OF BIRTH:_________________________SEX:________

PERMANENT ADDRESS: ________________________________________________

_______________________________________________________________________

LOCAL ADDDRESS (if different): __________________________________________

_______________________________________________________________________

TELEPHONE NUMBERS:_________________________________________________

EMAIL(S): ______________________________________________________________

FATHER’S NAME: ___________________________________________AGE:_______

EMPLOYER: ____________________________________________________________

ADDRESS: _____________________________________________________________

WORK TELEPHONE: _____________________________________

TYPE OF WORK: ________________________________________________________

MOTHER’S NAME: ___________________________________________AGE: _____

EMPLOYER: ____________________________________________________________

ADDRESS: _____________________________________________________________

WORK TELEPHONE: ______________________________________

TYPE OF WORK: ________________________________________________________

CHILD LIVES WITH: ____________________________________________________

NAME AND TELEPHONE OF EMERGENCY CONTACT: ______________________

Please indicate how you were referred (please specify):_________________________________________________________________________

MEDICAL INFORMATION

NAME OF PATIENT:_________________________________Allergies___________________________

FAMILY MEDICAL HISTORY

NAMES AND AGES OF ALL SIBLINGS: __________________________________________________

______________________________________________________________________________________

Please list all family members, including the natural mother and father, grandparents, aunts, uncles, first cousins, brothers and sisters who have any chronic or serious illness or conditions related to that of the patient. In addition, if there are any known inherited conditions that have occurs in any family member, however related, please list.

PRENATAL AND BIRTH HISTORY

1. Is the patient adopted? ______________
2. How many weeks was the birth mother pregnant (40 weeks is the due date)? _____________
3. What type of delivery (e.g. vaginal, cesarean, vacuum, etc.) ______________________
4. If other than vaginal, why? ________________________________________
5. What anesthesia or pain medicines used during labor or delivery? _______________________
6. Were treatments used to start (induce) or strengthen contractions? _______________________
7. Were any antibiotics given during labor, delivery, or after delivery (include details)? ________ _____________________________________________________________________________
8. Please list all medical conditions known for the birth mother:________________________________________________________________________
9. Place of birth: _____________________________________
10. How long was the baby in the hospital? _________________________________________
11. Measurements at birth: weight _________ length: __________
12. During the first month of life did the baby have any illnesses or problems, take medicines or have any tests other than routine tests (include details)? ______________________________________
13. During the pregnancy were there any illnesses or treatments (include details)? ________________

_______________________________________________________________________________

13. Has the birth mother ever during her life had any vaginal infections (include details)? __________
14. What vitamins and/or other nutritional supplements were taken during the pregnancy? _________ _______________________________________________________________________________

DIETARY HISTORY

1. How long did the patient breast feed? _____________________
2. During breastfeeding did the mother experience any breast related problems, including sore nipples, plugged ducts, breast itching/pain or mastitis (include details)? _________________ __________________________________________________________________________
3. What formulas did the patient take and at what ages? __________________________________
4. When did he/she begin solid foods? ________________________
5. What vitamins or nutritional supplements is the patient taking? ___________________________
6. Please describe the current diet: ____________________________________________________ ______________________________________________________________________________
7. How much water does he/she take daily? __________________
8. List foods he/she craves: __________________________________________________________
9. How often does he/she have a bowel movement? _____________________
10. What are the bowel movements like? _____________________________________________
11. Describe any symptoms related to any particular foods: __________________________________ _______________________________________________________________________________

MEDICAL HISTORY

1. List and describe any hospitalizations: ________________________________________________ _______________________________________________________________________________
2. Describe any accidents, falls or other injuries: _________________________________________ _______________________________________________________________________________
3. Surgeries: ______________________________________________________________________
4. Childhood illness and year(s) (e.g. chicken pox, measles, mumps, rubella): __________________
5. How many ear infections? _______
6. How many throat infections treated with antibiotics? ______
7. Pneumonia or bronchitis (details): ___________________________________________________
8. Has he/she ever been treated for thrush or other fungal infections or been treated with antifungal medications by mouth or on the skin? ___________________________
9. Are there any other illnesses that are a concern to you (include details)? __________________ ____________________________________________________________________________
10. Are his/her vaccines/immunizations current? _______
11. Has he/she or any family member had reactions to any vaccines? _______________________
12. Please list all medications he/she is taking: __________________________________________ _____________________________________________________________________________
13. Does anyone smoke anywhere around the patient? __________
14. Have there been any concerns related to either growth or development (speech, motor, etc.) _______ (detail on the back of this page)

Dr. Rydland strives to provide you with complete medical evaluations and appropriate treatment options for all of your children’s medical conditions. We want to do all we can to restore vibrant health and not just focus on eliminating disease. To do so we need to have regularly updated information about your child’s change(s) in condition and recommendations of other treating practitioners. Please have any specialists or other practitioners forward information regarding their evaluations and proposed treatments or send us this information yourself. Dr. Rydland is available for telephone calls after regular office hours, but will either need to see your child or do a telephone consultation regarding some more involved conditions. There is a charge for some telephone consultations and an additional charge for office visits performed outside of our normal business hours. I understand that I will be charged a non-cancellation fee if I do not cancel a scheduled appointment at least 48 hours in advance.

Not all medical services are covered by medical insurance. Although we recommend you contact your insurance company prior to any medical treatments or tests, it is important to understand that they may later deny coverage for any of these. We do our best to supply you with the necessary information to bill your insurance, but cannot be held responsible for the errors of the insurance companies.

Signature __________________________________________________ Date: ______________________