Child Intake Form (Newborn to 15 years old) Step 1: Informed Consent NOTE TO CLIENT: We require your informed consent. This means we want you to understand the services we hope to provide to you and what we do with the personal Information we obtain about you. We work to provide you with health care services that meet your needs and enable you to seek those services at organizations across the province. In doing so we may need to share your personal health information via fax or an electronic sharing system with other health service providers who are involved in your care. Please read the following in its entirety and agree to the declaration at the end of this page before proceeding to fill out the patient intake form. ✓ I understand that I may access services at the Essex County Nurse Practitioner-Led Clinic. The type and extent of services, available options for services, and the risks and benefits of services have been explained to me. I have had the opportunity to ask questions about the services provided. ✓ I understand that I have specific rights and responsibilities related to my care. If I choose to participate in ongoing service I understand I will receive additional information about programs, services, privacy and safety. ✓ I understand that the agency will collect, use and disclose my personal health information for the purposes of referral, consultation, assessment and provision of services. ✓ I understand that an electronic sharing system may be used to share my personal information and/or prescription drug information history with other health service providers, who may need to review the data in order to provide services to me. I understand I may withdraw consent to sharing my assessment and/or prescription drug information in the electronic sharing system at any time. ✓ I also understand that this personal health information may be used and electronically shared with other individuals and service providers such as doctors, nurses, care givers, community care providers and other organizations involved in my care in order to provide the most comprehensive services possible. ✓ I understand that my use of services and my personal health information will remain secure and confidential. Disclosure of information to others outside those involved in my care will only be made with my consent. I further understand that there are specific exceptions to this confidentiality as explained to me. Note: The organization has a responsibility to report suspected and/or disclosed reports of abuse, neglect and/or intent to do harm to self or others. ✓ I agree that the information was provided to me in simple, easy to understand language and addressed my cultural beliefs and preferences. Name: I declare I have read, understood and agree to the contents of the Informed Consent Agreement in its entirety. By submitting this form, I confirm I understand the purpose for which my personal health information is collected, used and shared and my privacy rights. NextStep 2: Personal Data Thank you for your interest in becoming a client at Essex Nurse Practitioner Led Clinic. The ECNPLC collects, uses and discloses personal information in compliance with the guidelines of the Personal Health Information Policy Act (PHIPA). The priority of the ECNPLC is to provide primary health care services to residents who live in Essex and surrounding communities who do not have a primary care provider. Please answer the following questions to the best of your knowledge. Preferred Location Please select the ECNPLC location you are registering for: —Please choose an option—EssexWindsor (Drouillard)AmherstburgKingsville Personal Data Child's Name: Date of Birth: Gender: —Please choose an option—MaleFemale Health Card Number: Version Code: Exp Date: Street Address: City/Town: Parents/Guardians: Parent #1: Phone: Parent #2: Phone: Who lives in the household? (check off all that apply) MotherFatherSisterBrotherOther If other, who? Total number of people in the home: Email of parent: Do you consent to receiving email communication? This form of communication will not include any personal health information and is strictly one-way. You will not be able to email us. YesNo Name and location of the pharmacy you use: Does your child have a current or previous primary care provider (Nurse Practitioner / Family Physician)? YesNo Name of Child's current/previous health care provider: List any previous specialists the child has seen in the past: BackNextStep 3: Birth History This child is: —Please choose an option—Biological (by birth)AdoptedStep-childFoster Was the pregnancy full term? —Please choose an option—YesNoDon't know Were there any complications with the pregnancy or delivery? —Please choose an option—YesNoDon't know If yes, please explain: Child's weight at birth: Growth and Development Have you or any previous care providers had any concerns with your child's development (speech, language, social skills, or motor skills)? If yes, please include as much detail as possible. BackNextStep 4: Medical history Has your child had any of the following conditions? Serious medical illness YesNo Details: Asthma/wheezing/breathing problems YesNo Details: Hospitalization and/or surgery YesNo Details: Broken bones/injuries YesNo Details: Behavioral problems YesNo Details: Depression or anxiety YesNo Details: Other? YesNo Details: Please list allergies to medications, food, or environment (penicillin, dust, pollen, dogs, etc.) Please list current medications, vitamins, and supplements (even if not used every day) or attach a copy of an up-to-date medication list from your pharmacy. Do you have an extended drug plan? (eg Greenshield, Desjardins, Sunlife) YesNoBackNextStep 5: Family History Please indicate if any blood relatives have suffered any of the following conditions. If yes, please indicate which family members (e.g. Parent, sibling, grandparent, and, uncle, etc.) had the condition. Alcoholism/Drug use? YesNo Who? High cholesterol? YesNo Who? High blood pressure? YesNo Who? Stroke? YesNo Who? Mental health problems YesNo Who and what type? Diabetes YesNo Who and type? Cancer YesNo Who and what type? Bleeding/clotting disorder YesNo Who? Genetic disorder YesNo Who and what? Asthma/COPD YesNo Who and which one? Diet and Exercise Is your child physically active? YesNo How do you rate your child's diet? GoodFairPoor Is your child a picky eater? YesNo Does the child use any of the following? (check all that apply) NoneAlcoholDrugsTobacco Is the child exposed to second hand smoke in the home? YesNoBackNextStep 6: Immunizations Please provide a detailed list of the child's immunizations/vaccinations and the date received: Please list any other information or health concerns that you feel we should know. I understand that the information I have provided is accurate to the best of my ability. I understand that this information will remain private and confidential, only to be used by the medical personnel at ECNPLC. Back
