UPDOX - PATIENT PORTAL

Patients name * Patients DOB * Accompanied by: * Relationship to Patient * Allergies Present concerns/complaints

DAILY LIVING

How many days a week does your child eat breakfast? How many fruits and vegetables does your child eat in a day? How many juice,soda, or sweetened drinks does your child drink in a day? How many meals each week does your family eat at hometogether? How much time (outside of school and work) does your child spend watching a screen (TV, computer,etc.) How many hours a day is your child physically active (walking,running,playing,etc?) How many hours of sleep does your child get each night? Milk - Whole or 2% and how many ounces a day? Meals how many servings each day of: Cereal, Fruit,Veggies, Meat Any access to weapons? Any stressful/abusive situations in the household? Any smoking in the household / care givers Is seat belt used at all times? Has he/she ever had sex? Has he/she ever used tobacco, alcohol, or drugs? Home have smoke alarms? How many friends does your child have? How many hours does patient work outside home? School performance - grade level? Grade in classes?

Girls

First period? Last period? How often? How many days does it last? Cramping? What are patients future plans? When was the last dental exam? Who all lives in the home? Has household chores? Have allowances? Describe after school activities Describe any personality or behavior problems Electronic Signature of Guarantor/Guardian * Name and DOB of Guardian completing form * Today's date *