nAJEM Pediatric Clinic

New Child Patient /
Family And Insurance Information Form

Today is Thursday/21/11/2024

Patient's Name

Date of Birth

Age

What is your child's gender?

*Attenion: If you do not include a proper home address in the fields below, you're form will be discarded/deleted immediately. Answers such as n/a are not acceptable answers. We need a complete and accurate address to be able to bill you for our services, as well as creating a medical record for you.

Patient's Parental Information

Father's Name

First Name

Last Name

Father's D/O/B

Father's Martial Status

Martial Status

Father's Address

Street

City

State

Zip Code

Father's Email

Father's Phone

Cell Phone

Home Phone

Father's Employer Name

Employer Address

Street

City

State

Zip Code

Father's Work Phone

Mother's Name

First Name

Last Name

Mother's D/O/B

Mother's Address

Street

City

State

Zip Code

Mother's Email

Mother's Phone

Cell Phone

Home Phone

Mother's Employer Name

Employer Address

Street

City

State

Zip Code

Mother's Work Phone

Mother's Martial Status

Emergency Contact

Full Name

Emergency Contact Phone

Emergency Contact Relationship

Who referred you to our office?

* Please read the following statements and check the boxes if you agree.

Assignment of Benefits: Assignment of Benefits: I authorize the payment of Medical benefits to Najem, M.D. for the professional services rendered to my children. I understand that I am financially responsible for all the charges for services rendered to my child by Najem, M.D. including the balance remaining after the payment of possible insurance benefits.

Parent Name or Representative (if guardian).

Full Name

Relationship to Child

Today's Date

By checking this box, I am electronically signing this form.

Meaningful Use Form

Meaningful Use: Dr. Najem would like to thank you for taking the time to complete this short questionnaire. We apologize for any inconvenience. Electronic Health Records serve as an important facilitator for collecting patient demographic data. The 2009 economic stimulus bill and 2010 health system reform bills, both strongly encourage collection of this data. Due to recent government initiatives to promote the use of electronic health records and in compliance with Meaningful Use, the reporting of the patient's racial background is now a requirement. Please complete the following information regarding the patient who is being seen today.

Patient's Name

Pharmacy Name

Pharmacy Phone

This office may ePrescribe (send prescriptions electronically to your pharmacy) and view my external history prescriptions (prescriptions written by other doctors).

yes

Ethnicity

How would you describe the patient's ethnicity? If you are uncomfortable answering the questions, you may select "Decline to answer".

Choose one

Language

I authorize Vinaya K. Najem MD to release any medical records when I request them to be shared.

yes

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This practice uses and discloses health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. Treatment We are permitted to use and disclose your medical information to those involved in your treatment. For example, your care may require the involvement of a specialist. When we refer you to a specialist, we will share some or all of your medical information with that physician to facilitate the delivery of care. Health Care Operations We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this practice and ensure that quality care is delivered. For example, we may engage in the services of a professional to aid this practice in its compliance programs. This person will review billing and medical files to ensure we maintain our compliance with regulations and the law. Disclosures That Can Be Made Without Your Authorization There are situations in which we are permitted by law to disclose or use your medical information without your written authorization or an opportunity to object. In other situations we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization, in writing, to stop future uses and disclosures. However, any revocation will not apply to disclosures or uses already made or taken in reliance on that authorization.

I have read and agree with the above notice of PRIVACY PRACTICES.

yes

Patient's Name

Relationship to Child

Today's Date

By checking this box, I am electronically signing this form.

Questionaire

Briefly describe your child's symptoms

When did your child's symptoms start

Date

On a scale of 1-10 (10 being the worst) rate your symptoms

Has your child's teacher(s) complained about your child?

yes

Have you had family and or friends complain about your child?

yes

Have you lived in a home built before 1960?

yes

How has your child's school performance been in the last year?

DSM-IV Questionaire (Please select yes or no for each symptom)

1) Some symptoms of hyperactivity-impulsiveness or inattention present before age 7.

yes

2) Some impairment observed in at least 2 settings (e.g., school and home)

Yes

3) Clear evidence of interference with social, academic or work function.

Yes

4) No other mental disorders present (e.g., mood, anxiety, dissociation or personality disorder)

Yes

Symptoms of Hyperactivity and Impulsivity Symptoms: Please be sure to select Yes or No for each question.

5) Often fails to pay close attention to details or makes careless mistakes in schoolwork, work, or other activities.

Yes

6) Often has difficulty maintaining focus on tasks or play activity.

Yes

7) Often does not seem to listen when spoken to directly.

Yes

8) Often does not follow through on instructions and fails to finish schoolwork, chores or other responsibilities (not due to behavior or failure to understand instructions)

Yes

9) Often has difficulty organizing tasks and activities.

Yes

10) Often avoids, dislikes, or is reluctant to take part in activities that require continuous mental effort, such as schoolwork or homework.

Yes

11) Often loses things needed for tasks or activities, such as toys, assignments, books, or tools.

yes

12) Is often easily distracted by extraneous stimuli.

Yes

13) Is often forgetful in daily activities.

yes

Symptoms of Innatenttion: Please be sure to select Yes or No for each question.

14) Often fidgets with hands, feet or squirms in seat.

Yes

15) Often runs around or climbs excessively in situations in which it is not appropriate.

Yes

16) Often leaves seat in classroom or in other situations in which staying seated is expected.

Yes

17) Often has difficulty playing or engaging in leisure activities quietly

Yes

18) Is often "on the go" or often acts as if "driven by a motor"..

yes

19) Often talks excessively..

Yes

Thank-you for filling out and submitting the form.

Resources

ADHD Clinic
Baby/Young Child
Pre-teen/Teens
Commom Childhood Illnesses
Privacy Policy

Clinic Hours

Mon: 8am-6pm
Tues-Thurs: 12pm-6pm
Fri: 8am-2pm
Sat: 8am-12pm