The Childrens Clinic of Nashville, P.L.C.

Patient Consent for Use And Disclosure

Of Protected Health Information

For your convenience you may print out the "Hippa Consent Form" ahead of time to pre-fill out and bring with you. You may also enter the Patients name as well as the Parent or Legal Guardian's name which will be clearly printed to help us minimize any confusion due to handwriting. If you prefer to hand-write your "Hippa Consent Form" simply press the button below labeled Generate and Print PDF and a blank form will be generated.

Patient

Patientâ€™s Name:

Patientâ€™s DOB:

Mother

Mother's Name:

Mothers age:

Mother's Occupation:

Father

Father's Name:

Father's age:

Father's Occupation:

pregnancy and birth

Mother's age at birth:

Did your mother have any illness during pregnacy:

no yes

Did she take any medications other than vitamins?:

no yes

Was the baby on time?:

no yes

What was the birthweight?:

Did the baby have any trouble starting to breathe?:

no yes

family history

Are the child's parents both in good health?:

no yes

List age, sex and general health of brothers and sisters:

Have any of your children died:

no yes

Feeding and Nutrition

Is your child's appetite usually good?:

no yes

Was there severe colic or any unusual feeding problems during the first 3 months?:

no yes

Is your child breast or bottle fed?:

breast bottle

If breast fed, how long was the child breast fed?:

If using formula, which brand?:

Does he/she take vitamins?:

no yes

Safety and Enviroment

Do you live in a private house, apartment, or mobile home?:

no yes

Do you know the hottest temp. of water in your pipes?:

no yes

Are there working smoke alarms on each floor of your house?:

no yes

Does your child always use a car seat/seat belt?:

no yes

Are there any smokers in the household?:

no yes

Does your child always wear a helmet when riding a bicycle?:

no yes

past medical history

Where has your child gone for check-up until now?:

Date of last check-up?:

Has your child had reactions to any immunizations?:

no yes

Which Ones:

Has your child had allergic reactions to any medications foods, or insect bites?:

no yes

Which Ones:

Any hospitalizations other than birth?:

no yes

For What:

Any serious injuries?:

no yes

What Kind?:

Are any medications taken regularly?:

no yes

Which ones?:

development and behavior

At what age did your child sit alone?

At what age did he/she walk alone?:

Did he/she say any words by the time he/she was 1 1/2 years old?:

no yes

How does this child compare to other children his/her age?:

What grade is your child in?:

Has he/she had any trouble in school?:

Does he/she get along with other kids?:

no yes

review of systems

Does Your Child Have A History Of Any Of The Following:

Frequent ear infections- 6 or > per year:

no yes

Eye problems?:

no yes

Teeth Problems?:

no yes

Frequent colds or sore throat?:

no yes

Pneumonia, asthma or cough?:

no yes

Frequent urination?:

no yes

Heart murmur or heart problems? :

no yes

Diarrhea or constipation?:

no yes

Convulsions or other problems with the nervous system?:

no yes

Has your child ever been anemic?:

no yes

Please list any other medical problems:

Do you have a record of your child's immunizations?:

no yes

If adults in the household work outside of the home, what child care arrangements are made for this child?:

Day Care Phone Number:

4322 Harding Pike, Suite 313
Nashville, TN 37205
(615) 297-9541