31569 Canyon Estates Drive Suite #225, Lake Elsinore, Ca. 92532 P (951)228-9010 F (951)609-2080

PATIENT INFORMATION / REGISTRATION New Patient ___ Change of Address/ Insurance ___ Date _____/____/______ Patient / Child’s Name: Last _________________________________ First ________________________________ M.I. ______ D.O.B_________________ Gender M____ F____ SSN ________-______-__________ Race _____________ Ethnicity _____________Religion_____________ Patient’s Address_________________________________________________________ City_______________________ Zip _________ Cellphone (______) _________________ Home phone (______) ________________ Preferred Phone (______) ________________ E-mail: ______________________________ Preferred Language ________________________ Translation Needed? ___________ Submit Vaccines Records to CA vaccines registry? Yes__ No__

PARENT/ GUARANTOR Mother’s Name Last _________________________ First _____________________D.O.B _________________ SSN ______-_____-______ Home Address (same as patient) ______________________________________________ City _______________ Zip __________ Cellphone (______) _______________ Home phone (______) _______________ Work phone (______) _______________ Father’s Name Last _________________________ First ____________________D.O.B _________________ SSN ______-_____-_______ Home Address ( same as patient) ______________________________________________ City _______________ Zip __________ Cellphone (______) _______________ Home phone (______) _______________ Work phone (______) _______________ EMERGENCY CONTACT (other than parents/legal guardian) Name _________________________________________________________ Relationship to patient ___________________________ Address ________________________________________________________ City ___________________________ Zip ____________________ Cellphone (______) __________________ Home phone (______) __________________ Work phone (______) _________________ Completed by ______________________________________ Patient relationship: Mother/ Father/ Foster parent/ legal guardian/ other________ How did you hear about our office? ___ Yelp ____ Google ___ Friend ___ Insurance ___ Others ___ Flyers ___

CHILD HEALTH HISTORY

HISTORY OF PREGNANCY WITH THIS CHILD:

During which month of pregnancy did you first see the doctor? Month How long was your pregnancy? Months

Where was baby born?

If baby was born at home, were blood tests for newborn screening done? Yes No

Did you have any illnesses or problems? (including sexually transmitted or other communicable diseases)

YES NO Did you use any non-prescribed drugs? (tobacco, alcohol, “street drugs:, over-the-counter or home remedies)

YES NO

Did you take any medications prescribed by your doctor? YES NO Did the baby go home with you from the hospital? YES NO

Did you have a difficulty/abnormal delivery/C-section? YES NO Was more than one baby born? YES NO

Did the baby have any problems during the 1st week of life? YES NO Did baby receive any shots for Hepatitis B? YES NO

CHILD’S HISTORY: Male Female Is this child adopted? YES NO Birth Weight: pounds ounces Length: inches

Has your child ever had (Please circle Yes or No):

Measles, Chickenpox, Mumps, Rubella YES NO Vomiting after eating, refusal to eat YES NO

Tuberculosis or positive TB Test YES NO Muscle, joint or bone problems YES NO

Tonsillitis/Sore Throat YES NO Skin problems YES NO

Problems with eyes or vision YES NO Headaches or dizziness YES NO

Problems with ears or hearing YES NO Convulsions, seizures, epilepsy YES NO

Difficulty breathing/snoring at night YES NO Diabetes YES NO

Heart problems YES NO Thyroid problems YES NO

Asthma, bronchitis, or pneumonia YES NO Allergies YES NO

Anemia, bleeding problems, blood transfusions YES NO Problems with development of school performance YES NO

Stomachaches YES NO Serious illness or accident YES NO

Diarrhea, Soiling self with stool YES NO Surgery or hospitalization YES NO

Bladder Kidney Problems, Wetting self or bed YES NO (GIRLS) Has she stared her periods? YES NO

Constipation YES NO (GIRLS) Are there problems with her periods? YES NO

FAMILY HISTORY: Does mother (M), father (F), brother (B), sister (S), aunt (A), uncle (U), or grandparent (GP) have:

Which Family Member? Which Family Member?

YES NO Diabetes YES NO High blood pressure

YES NO Epilepsy or convulsions YES NO Bleeding disorder

YES NO Mental retardation YES NO Tuberculosis

YES NO Heart disease YES NO Allergy

YES NO Cancer YES NO Lung or breathing problems

YES NO Kidney or urinary disease YES NO Eye disorder

YES NO Bone or joint problems YES NO Ear disorder

PARENT INFORMATION:

Mother: Father: Age: Height: Occupation:

HOUSEHOLD INFORMATION: Number of people in home

Are both parents living in the home? Yes No

Does anyone in the home smoke, or use drugs or alcohol? Yes No Language spoken in the home:

Do you live in a: House Apartment Mobile Home Shelter Homeless

Patient Identification: Signature: Date: _____________ Relationship to Child:

Reviewer’s Signature: __________________________________ Date: _______________

State of California—Health and Human Services Agency Department of Health Services Child Health and Disability Prevention (CHDP) Program

Adapted from the Orange and San Bernardino Counties CHDP Programs. DHS 4035 A (10/03)

Baby: Birth to 24 months

Yes / No � � Breast-fed 8–12 times/24 hours during early weeks of lactation OR every 3–4 hours/day for older infants?

� � Formula-fed w/iron no less than 20 ounces/day? Correct dilution?

� � No honey/Karo Syrup until 1 year?

� � 4–6 months: t on baby cereal with iron?

� � 5–7 months: t on pureed vegetables and fruits?

� � 6–7 months: Drink from a cup?

� � 6–8 months: t on pureed or ground meat, i.e., poultry, beef, pork, fish, egg yolk, beans, tofu?

� � 7–9 months: ats finger foods and mashed/chopped foods, NO grapes, nuts, popcorn, hotdogs, hard candy?

� � 1 year: Drinks regular milk no less than 16 ounces/day?

� � 9–12 months: joins family meal and snack times?

� � 12–24 months: ats variety of foods: small portions, i.e., 1–2 Tbsp., ½ c juice, ½ slice of bread.

Child: 2 to 8 years

Yes / No � � Eats recommended variety and amounts of foods daily for age from the food guide pyramid?

Mealtime/Others:

Yes / No � � Set meal and snack times?

� � Brush teeth by himself at 5 years?

� � Good food supply?

� � Takes vitamins, iron, or fluoride?

� � Growing normally according to his/her growth patterns?

� � Does child play with or eat dirt, plaster, clay, and paint chips?

� � Any food intolerances or allergies? ______________________

� � Referral for identified nutrition problem? Where? ___________________

Activity: � � Actively plays everyday, i.e., running, biking, sports, 1 hour/day?

� � TV viewing: 2 hours or less/day?

What Does Your Child Eat? Circle the foods your child eats every day or at least 3 times per week:

Fruits and Vegetables/Vitamin A, C, Folic Acid, and Fiber Rich Foods

Circle if your baby or child receives food from:

Food Stamps

WIC

Office Use Only Feeding milestones to check/visit

Child’s name:___________________________________ Record #:______________ Age: _ yrs. _____ mos. ____ lbs. Ht: ______ in. Date: ____/____/___

Circle activities your baby or child does every day.

Breads, Grains, and Cereals

Milk Products/Calcium Rich Foods Protein/Iron Rich Foods

Circle if baby/child uses:

Salad

Ham/Pork

Baby Foods

Other Foods

1% Milk/ Skim Milk

Whole Milk

Squash (zucchini) Dark Green Leafy Vegetables

Calcium Fortified

100% Juice Nonfat/Lowfat yogurt

Nonfat/Lowfat Cottage Cheese

Cheese

Calcium Fortified Tofu

How does your child feel about mealtimes?

Rice

Honey

Calcium Fortified Soy Milk

French Fries

Spaghetti With Meatballs Tofu

Chicken/Turkey

Corn Syrup

Juice

Tofu

Crackers

Burrito Cookies

Bread/Bagel

Crackers

Milk Shake

Candies Chocolate Bar

Cereal with iron Tortilla

Beef

Fried Chicken

Taco

Sweet Breads

Soup Noodles

Broccoli

Cauliflower

Cabbage

Flavored Drink

Fish/Canned Fish

Breast Feeding

Dried beans/Lentils

Cantaloupe Peaches

Raisins Orange Tomato

Green Beans & PeasPotatoes/

Sweet Potatoes

Chips

Drinks water?

Carrot

Watermelon Pineapple

Corn

Strawberries

Banana

Pear

AppleGrapes

PretzelsPasta

Ice Cream

Egg

Hamburger

Pizza

Hotdog

Egg

Beans

100% Juice

C

Mango

A

Peanuts

Cereal with iron

Formula with iron

Vitamins

LimitFats and Sweets

Breads, Grains, and Cereals6-11 servings

Protein(Iron)

Milk (Calcium)

Vegetables Fruits

2–3 servings 2–3 servings

3–5 servings 2–4 servings

Bell Pepper/Chili

Star

Star

Star

E

Feeds self,

E

Head School StartLunch

____ Wt: __

pso#BusPatient Partnership Plan

Dear Patient:

Welcome to our practice. We intend to provide you with the care and service that you expect and deserve.Achieving your best poss/.b/e bea/fh requires a "partnership" between you and your child's doctor. As our"partner in health," we ask you to help us in the following ways:

Schedule Visits with my children's Doctor for Routine Physical Exams and Other RecommendedHealth ScreeningsI understand that my child's doctor will explain to me which regular health screenings are appropriate for mychildren's age, gender, and personal and family history. I understand my child will need to complete theserecommended health screenings. These health screenings are tests that can help detect life-threateningdiseases and conditions. If I visit my children's doctor only for treatment of immediate problems and forget toarrange for regular health screenings, I put my children at risk of letting serious health problems go undetected.I will schedule regular visits with my children's doctor to complete physical exams and to discuss these healthscreenings.

Keep Follow-up Appointments and Reschedule Missed AppointmentsI understand that my child's doctor will want to know how my condition progresses after we leave the office.Returning to my child's doctor on time gives him the chance to check my child's condition and response totreatment. During a follow-up appointment, my child's doctor might order tests, refer to a specialist, prescribemedication, or even discover and treat a serious health condition. If my child misses an appointment and don'treschedule, my child has the risk that the physician will not be able to detect and treat a serious healthcondition. I will make every effort to reschedule my child's missed appointments as soon as possible.

Call the Office When I Do Not Hear the Results of Labs and Other TestsI understand that my child's physician's goal is to report lab and test results to me as soon as possible.However, if I do not hear from my child's physician's office iwithin the time specified, I will call the office for mytest results. I

Inform My Doctor if I Decide Not to Follow His Recommended Treatment PlanI understand that after examining my child, doctor may make certain recommendations based on what he feelsis best for my child's health. This might include prescribing medication, referring my child to a specialist,ordering labs and tests, or even asking me to return to the office within a certain period Of time. I understandthat not following treatment plan can have serious negative effects on my child's health. I will let Doctor Fayadknow whenever I decide not to follow his recommendations so that he may fully inform me of any risksassociated with my decision to delay or refuse treatment.

Thank you for your partnership. As our patient, you have the right to be informed about your child's health care.We invite you, at any time, to ask questions, report symptoms, or discuss any concerns you may have. If youneed more information about your health or condition, please ask.

Patient Signature Physician Signature

Today’s Date: ______/______/_________

Patient’s/Child’s Name: ______________________________________________________ Date of Birth_____/_____/_______ Last First M.I. CONSENT TO TREAT/ TREAT A MINOR/CHILD: I, ____________________________________________________________, the parent/legal guardian of the child/minor named in this document, give the permission to the health care provider to administer such examination, treatment, testing, vaccinations, medical plan and procedures as are deemed necessary in the course of the child/minor care. AKNOWLEDGMENT OF RECIEPT OF NOTICE OF PRIVACY PRACTICE (HIPPA): I understand and have been provided with a notice of privacy practices (privacy notice), which provides a more complete description of information and disclosures. I understand that I have a right to review the notice before signing it. I understand that I have the right to revoke this consent in writing, except to the extent that the healthcare provider has already taken action on my behalf. I, the parent/legal guardian of the patient named in this document, have received a copy of this office’s Notice of Privacy Practice. SUBMISSSION OF VACCINES INFO TO CA IMMUNIZATION REGISTRY (CAIR) I, the parent/legal guardian of this patient give permission to Pediatrics R US to submit vaccines records to CA Registry (CAIR). FINANCIAL RESPONSIBILITY: Information about me necessary to substantiate my insurance claims may be used by the healthcare provider involved in my care. I hereby authorize any insurance carrier with whom I have a policy to pay directly to the healthcare provider any benefits of any policies of insurances to the healthcare provider who has rendered the service to me and who accept such assignment. I agree to pay all charges that are not paid in full by assigned insurance. If such amounts due to the healthcare provider are not paid after reasonable notice, that account shall be deemed delinquent and a service charge fees shall be added to the amount due. In the event that I default on payment of my account, I agree to be responsible for the collection fees and interest due on amounts in default, including court costs and reasonable attorney’s fees. If the debt is assigned to a third party for collection, I agree to be responsible for collection fees and interest due on amount in default. OFFICE FINANCIAL POLICY:

PAYMENTS/CO-PAYS: The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due and payable at the time of service. The patient/parent is expected to inform the office with any change of health plan/insurance or contact information at each visit.

SELF-PAY ACCOUNTS: Self-pay accounts are patients covered by insurance plans in which the provider does not participate, patients without an insurance card on file, or patients who do not have any insurance coverage. The parents shall pay in full at the time of service.

NON-PARTICIPATING INSURANCE PLANS: we will file to these insurance plans as a non-assigned claim as a courtesy to our patients. The parents shall pay in full at the time of service. The insurance company may or may not reimburse the parent on non-assigned claims.

PATIENT REFUNDS: The following criteria must be met prior to issuing a patient refund: there are no outstanding insurance claims on the family's account, and there are no outstanding patient balances on the family's account.

CHILD CUSTODY CASES: The custodial parent is responsible for co-payments at the time of service for participating instances and for all past due balances. If the non-custodial parent carries the insurance, the office will bill that insurance company. It is the parents' obligation to work out an agreement and insure payment to our office.

AFTER HOURS: a fee may apply to any medical services rendered after hours including medical consult over the phone. CHECKS: we do NOT accept checks. FORMS FEE: a fee may be applied for School physical forms / sport physical forms / special letter/ vaccines records/ and medical records.

MISSING APPOINTMENT: $25.00 fee may be applied for missed appointment, unless canceled or rescheduled 24 hours in advance. By signing this document, I agree/ give permission on all items listed in this document. Parent;s Name ____ ______________________________ Relation to patient (Circle): Mother, Father, Foster parents, Legal guardian, Other ______ Signature_________________________________________________ Witness (Name and Signature) ____________________________________________________________ Title ____________ Date _______________