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YOUTH HEALTH QUESTIONNAIRE

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6028−12MR Rev. 01/30/18
YOUTH HEALTH QUESTIONNAIRE
CURRENT MEDICATIONS (may bring own list to visit if you prefer)
ALLERGIES
PAST MEDICAL HISTORY
Page 1 of 3
Outside Note Other
Patient Name:
DOB: AGE:
Sex: ❏ M ❏ F
Patient Identification Area
Name of Medication
Strength of Medication
Dosing Instructions
* Note − this information may be taken directly from the pharmacy label on prescription products
❏ No Known Allergies ❏ Medication Allergies ❏ Environmental/Seasonal Allergies ❏ Latex Allergy
Please specify Allergen AND Reaction below:
Please list medical history for this patient and if possible indicate the age at diagnosis for each condition.
❏ Allergies ❏ Asthma ❏ ADD / ADHD ❏ Congenital Defect ❏ Mood/Behavior Disorder
❏ Other
PAST SURGICAL HISTORY
Please list surgical history and hospitalizations for this patient and if possible list the age or year when surgery (or
hospitalization) was performed.
Date of Surgery or Hospitalization Age or Year
Surgery (Operation) or Reason for
Hospitalization
We would like to personally thank you for taking the time to complete this form. Doing so provides us with the information
necessary to make the most out of each and every healthcare visit together.
FAMILY HISTORY (Check all that apply)
SOCIAL HISTORY
Page 2 of 3
YOUTH HEALTH QUESTIONNAIRE
Patient Identification Area
❏ Allergies ❏ Anemia
❏ Asthma
❏ Cancer (specify)
❏ Diabetes
❏ Epilepsy/Seizure Disorder ❏ Heart Disease
❏ High Blood Pressure
❏ High Cholesterol
❏ Mental Illness
❏ Other (please list) −
Patient Name:
DOB:
Family Information
Mother’s Name:
Mother’s Occupation:
Father’s Name: Father’s Occupation:
Siblings: ❏ Yes ❏ No
Sibling Names and Ages
Guardian Name and Relationship (if applicable):
If parents live separately, where is the child’s primary residence?
Who lives at home?
Are there pets in the home? ❏ Yes ❏ No If yes, specify type and name
Does anyone in the home smoke? ❏ Yes ❏ No
Child Care and Education
Does this child attend child care? ❏ Yes ❏ No
If yes, what is the name of the child care center? If yes, how many hours per week?
Does this child attend school? ❏ Yes ❏ No
If yes, what is the name of the school?
If yes, what grade?
Do you have concerns about your child’s adjustment or performance in school? ❏ Yes ❏ No
If yes, please explain:
Learning Needs
Is your primary language English? ❏ Yes ❏ No If no, please note primary language:
How would you like health information about your child/youth presented?
❏ 1:1 Conversations with health care provider ❏ Reading Materials ❏ Classroom
Who makes up your household? (check all that apply):
❏ Single Parent ❏ Two parent household ❏ Siblings ❏ Others, not family
Interests / Hobbies / Recreational Activities:
We would like to personally thank you for taking the time to complete this form. Doing so provides us with the information
necessary to make the most out of each and every healthcare visit together.
6028−12MR Rev. 01/30/18
YOUTH HEALTH QUESTIONNAIRE
Patient Identification Area
Patient Name:
DOB:
Page 3 of 3
Tobacco Exposure
(check all that apply)
❏ Patient is a Smoker ❏ Smokers in Home ❏ Smoke outside only
Activity
(check all that apply)
❏ Exercise/Sports (Hours per day)
❏ Internet (Hours per day)
❏ TV / Computer Games (Hours per day)
❏ Text Messaging (Hours per day)
Sleep
(check all that apply)
❏ Takes Naps ❏ Sleeps with Parents ❏ Sleeps through the night ❏ Minimum 8 hours nightly ❏ Nightmare/sleep problems
Safety
(check all that apply)
❏ Uses bike helmet ❏ Car Seat Rear Facing ❏ Car Seat Front Facing ❏ Booster ❏ Seat Belt ❏ Carbon Monoxide Detector
❏ Smoke Detectors ❏ Radon Detectors ❏ Fire Arms in Home ❏ Pool/Spa ❏ Pet / Animals Type & Number
CONCERNS
Please list any concerns you have regarding the health of this child in the space provided.
Name and Relationship of Person Completing Form (print):
Signature:
Date:
We would like to personally thank you for taking the time to complete this form. Doing so provides us with the information
necessary to make the most out of each and every healthcare visit together.
6028−12MR Rev. 01/30/18
Page 1 of 2
8402−03MR Rev. 10/07/19
AUTHORIZATION FOR RELEASE OF PROTECTED
OR PRIVILEGED HEALTH INFORMATION
Mail or Fax To:
Release of Information
121 Inner Belt Road, Room 240
Somerville, MA 02143−4453
Phone: 617−726−2361
Fax: 844−918-0781
Please print all information clearly in order to process your request in a timely manner.
A. PATIENT INFORMATION
PATIENT NAME:
PATIENT DATE OF BIRTH:
PATIENT MEDICAL RECORD #:
PATIENT ADDRESS: APT. #:
CITY:
STATE:
ZIP CODE:
TELEPHONE CONTACT #:
DAY: ( )
EVENING: ( )
STREET:
PERMISSION TO SHARE: I give my permission to share my protected health information. Enter where you would like
information sent from, and to whom you would like the information sent.
B.
FROM: (e.g. hospital, clinic, or provider name):
Name:
Address:
Telephone Number:
PURPOSE: (check the appropriate box):
❏ Medical Care
❏ Insurance*
❏ Legal Matter*
❏ Personal*
❏ School
❏ Other (please specify)*
* Copying fees may apply
TO: (e.g. to whom you would like the information sent):
❏
Check here if the records are to be mailed to the patient at the
above address (section A), otherwise complete the information
below to indicate where you would like the information sent:
Name:
Address:
Telephone Number:
SEND BY:
Partners Patient Gateway (if available)
Secure Email (provide email address below)
Patient Email Address:
Paper Copy via Mail
Fax (provide fax number):
❏
❏
❏
❏
INFORMATION TO BE RELEASED (Please check all that apply, and specify dates):
C.
Medical Record Abstract/dates:
(e.g. History & Physical, Operative Report, Consults, Test
Reports, Discharge Summary)
Clinic Visit Notes/dates:
Discharge Summary/dates:
Lab Reports/dates:
Operative Reports/dates:
Pathology Reports/dates:
❏
❏
❏
❏
❏
❏
Radiation Reports/dates:
Radiology Reports/dates:
Photographs/dates (costs may apply):
Billing Records/dates:
Other (please specify below and include dates):
❏
❏
❏
❏
❏
PRINT
SAVE AS
RESET
Page 2 of 2
8402−03MR Rev. 10/07/19
AUTHORIZATION FOR RELEASE OF PROTECTED
OR PRIVILEGED HEALTH INFORMATION
D.Please check YES to indicate if you give permission to release the following information if present in your record:
HIV test results (PATIENT AUTHORIZATION REQUIRED FOR EACH RELEASE REQUEST.)
SPECIFY DATES:
Genetic Screening test results (SPECIFY TYPE OF TEST):
Alcohol and Drug Abuse Records Protected by Federal Confidentiality Rules 42 CFR Part 2 (FEDERAL RULES
PROHIBIT ANY FURTHER DISCLOSURE OF THIS INFORMATION UNLESS FURTHER DISCLOSURE IS
EXPRESSLY PERMITTED BY WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS OR AS
OTHERWISE PERMITTED BY 42 CFR PART 2.) This consent may be revoked upon oral or written request.
Other(s): Please List:
Details of Mental Health Diagnosis and/or Treatment provided by a Psychiatrist, Psychologist, Mental Health
Clinical Nurse Specialist, or Licensed Mental Health Clinician (LMHC) (I understand that my permission may not
be required to release my mental health records for payment purposes)
Confidential Communications with a Licensed Social Worker
Details of Domestic Violence Victims’ Counseling
Details of Sexual Assault Counseling
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
E. I understand and agree that:
Partners HealthCare System (PHS) cannot control how the recipient uses or shares the information, and that
laws protecting its confidentiality at PHS may or may not protect this information once it has been released to
the recipient
This authorization is voluntary
My treatment, payment, health plan enrollment, or eligibility for benefits will not be affected if I do not sign this form
I may cancel this authorization at any time by submitting a written request to the Department or Office where I originally
submitted it, except:
if PHS has already relied upon it (for example, once information is released, it will not be retrieved)
if I signed this authorization as a condition of obtaining insurance, other laws may provide the insurer with a right to
contest a claim under the policy or the policy itself
This authorization will automatically expire 6 months from the date signed unless otherwise specified:
I understand that if Partners maintains any of my records from outside providers, these will not be released unless I
specifically ask for them under "Other" in section C. Please include entity name, provider, and specific dates if known.
My questions about this authorization form have been answered
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❍
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➢ Patient’s Signature:
➢ Date:
➢ Print Name:
When patient is a minor, or is not competent to give consent, the signature of a parent, guardian, or other legal representative
is required.
➢ Signature of Legal Representative:
Date:
Print Name:
Relationship of representative to patient:
For Internal Use Only
Information Released/Reviewed By:
Date:
Clinic/Office:
Pick−up Identification:
❏ License ❏ State ID ❏ Passport ❏ Other Photo ID
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YOUTH HEALTH QUESTIONNAIRE

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Completed 11 February 2021

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