US Medical Forms · 中文
儿科接诊表格
⚠ 这是参考翻译，帮助您了解典型表格内容。这不是官方文件。您的医疗提供者的实际表格可能有所不同——请务必签署提供者自己的版本。
儿童信息 / Child Information
| English | 中文 | English — Help | 中文 — Help |
|---|---|---|---|
| Child's Full Legal Name | 儿童法定全名 | Enter the name exactly as it appears on the birth certificate or legal ID. This must match your insurance records. | 请按出生证明或法定身份证件上的姓名填写，必须与您的保险记录一致。 |
| Date of Birth | 出生日期 | Enter in month/day/year format (MM/DD/YYYY). The date of birth is used to verify insurance eligibility and to select age-appropriate screenings. | 请以月/日/年格式填写（MM/DD/YYYY）。出生日期用于核实保险资格并选择适龄筛查项目。 |
| Sex Assigned at Birth | 出生时性别 | Used for clinical screening guidelines and insurance records. Options typically include Male, Female, and Other/Unknown. This field reflects biological sex for medical purposes. | 用于临床筛查指南和保险记录。选项通常包括男、女和其他/未知。此字段反映医疗用途的生理性别。 |
| Home Address | 家庭住址 | Include street address, city, state, and ZIP code. This is used for billing, appointment reminders, and determining in-network care options in your area. | 包括街道地址、城市、州和邮政编码。用于账单、预约提醒，以及确定您所在地区的网络内医疗选项。 |
| Preferred Language | 首选语言 | The language in which you and your child are most comfortable receiving care and information. Federal law requires providers to offer qualified medical interpreters at no cost when needed — see our guide on interpreter rights for details. | 您和您的孩子最舒适的接受医疗服务和信息的语言。联邦法律要求医疗机构在需要时免费提供合格的医疗口译员——详情请参阅我们关于口译权利的指南。 |
父母/监护人信息 / Parent / Guardian Information
| English | 中文 | English — Help | 中文 — Help |
|---|---|---|---|
| Primary Guardian Name, Relationship, Phone, and Email | 主要监护人姓名、关系、电话及电子邮件 | The adult legally responsible for the child's healthcare decisions. Relationship options usually include Mother, Father, Stepparent, Grandparent, Foster Parent, Legal Guardian, or Other. Phone and email are used for appointment reminders, test results, and urgent clinical communications. Many practices offer a secure patient portal — ask about enrollment at your first visit. | 法定负责儿童医疗决定的成年人。关系选项通常包括母亲、父亲、继父母、祖父母、寄养父母、法定监护人或其他。电话和电子邮件用于预约提醒、检查结果和紧急临床通讯。许多诊所提供安全的患者门户——在首次就诊时询问如何注册。 |
| Secondary Guardian (if applicable) | 次要监护人（如适用） | Name, relationship, and phone for a second parent or guardian who may accompany the child or be contacted in an emergency. Leave blank if there is only one guardian. | 第二位可能陪同儿童就诊或在紧急情况下需要联系的父母或监护人的姓名、关系和电话。如只有一位监护人，请留空。 |
| Custody or Legal Guardianship Notes | 监护权或法定监护说明 | Use this field to note any custody arrangements, court orders, or restrictions that affect who may authorize treatment or pick up the child. The practice may request a copy of any court order on file. | 使用此字段说明任何可能影响谁可以授权治疗或接送儿童的监护安排、法院命令或限制。诊所可能会要求提供任何法院命令的副本备案。 |
保险信息 / Insurance Information
| English | 中文 | English — Help | 中文 — Help |
|---|---|---|---|
| Insurance Carrier Name | 保险公司名称 | The name of the insurance company as printed on the front of your insurance card (for example: Aetna, BlueCross BlueShield, United Healthcare, Medicaid, CHIP). If your child has no insurance, ask the front desk about eligibility for Medicaid or CHIP, or about sliding-fee options at community health centers. | 保险卡正面印刷的保险公司名称（例如：Aetna、BlueCross BlueShield、United Healthcare、Medicaid、CHIP）。如果您的孩子没有保险，请向前台询问Medicaid或CHIP的资格，或社区健康中心的浮动费用选项。 |
| Member ID and Group Number | 会员ID和团体号码 | Both numbers appear on your insurance card. The Member ID identifies the insured person; the Group Number identifies the employer or plan sponsor. Enter both exactly as shown — a mismatch will delay claims. | 两个号码都印在您的保险卡上。会员ID标识被保险人；团体号码标识雇主或计划发起人。请完全按照显示的内容填写——不匹配会延迟理赔。 |
| Insurance Policyholder Name | 保险持有人姓名 | The person in whose name the policy is held — often a parent or employer. If the child is the policyholder (for example, through CHIP or Medicaid), enter the child's name. Include their date of birth and relationship to the child. | 持有保险单的人——通常是父母或雇主。如果儿童是保单持有人（例如通过CHIP或Medicaid），请填写儿童姓名。包括其出生日期和与儿童的关系。 |
病史 / Medical History
| English | 中文 | English — Help | 中文 — Help |
|---|---|---|---|
| Known Medical Conditions | 已知疾病 | List any diagnoses the child has received, such as asthma, diabetes, ADHD, or heart conditions. If none, write 'None known.' This information helps the provider coordinate care and avoid conflicting treatments. | 列出儿童已获得的任何诊断，如哮喘、糖尿病、ADHD或心脏病。如果没有，请写'无已知疾病'。这些信息帮助医疗提供者协调护理并避免冲突治疗。 |
| Past Surgeries or Hospitalizations | 既往手术或住院 | List any operations or overnight hospital stays, including the approximate year and the reason. For example: 'Appendectomy, 2022' or 'Pneumonia hospitalization, 2021.' Leave blank if none. | 列出所有手术或住院经历，包括大致年份和原因。例如：'阑尾切除术，2022年'或'肺炎住院，2021年'。如果没有，请留空。 |
| Current Medications | 目前用药 | List all prescription medicines, over-the-counter drugs, vitamins, and supplements the child takes regularly. Include the drug name and dose if known (for example: 'Fluticasone 44 mcg inhaler, twice daily'). Leave blank if none. | 列出儿童定期服用的所有处方药、非处方药、维生素和补充剂。如果知道，请包括药品名称和剂量（例如：'氟替卡松44mcg吸入剂，每日两次'）。如果没有，请留空。 |
| Allergies (medications, food, environmental) | 过敏（药物、食物、环境） | List each allergen and the reaction the child had (for example: 'Penicillin — hives; Peanuts — anaphylaxis; Tree pollen — seasonal rhinitis'). Distinguishing a true allergy from a sensitivity or side effect helps the provider make safer prescribing decisions. | 列出每种过敏原及儿童的反应（例如：'青霉素——荨麻疹；花生——过敏性休克；树花粉——季节性鼻炎'）。区分真正的过敏与敏感性或副作用有助于医疗提供者做出更安全的处方决定。 |
| School or Daycare Name, Grade / Age Group | 学校或日托名称、年级/年龄组 | The school or daycare setting affects which vaccines or health screenings may be required for enrollment, and may also be relevant if the child has an individualized education plan (IEP) or needs accommodations. | 学校或日托环境影响入学可能需要哪些疫苗或健康筛查，如果儿童有个性化教育计划（IEP）或需要特殊安排也可能相关。 |
| Previous Primary Care Provider (if transferring) | 以前的初级保健医生（如转诊） | If the child previously had a pediatrician or family doctor, the new practice may request records. Providing the prior provider's name and practice helps coordinate the transfer. HIPAA gives you the right to request and receive a copy of your child's records from any prior provider. | 如果儿童以前有儿科医生或家庭医生，新诊所可能会要求提供记录。提供之前医疗提供者的姓名和诊所有助于协调转诊。根据HIPAA，您有权向任何之前的医疗提供者请求并获得您孩子记录的副本。 |
| Permission to Share Health Information with School or Daycare | 授权向学校或日托分享健康信息 | A yes/no consent field. When yes, the practice may share relevant health information (such as allergy action plans or medication instructions) directly with school nurses or daycare staff. You can revoke this consent at any time in writing. | 是/否同意选项。选择'是'时，诊所可以将相关健康信息（如过敏应急计划或用药指导）直接与学校护士或日托工作人员共享。您可以随时以书面形式撤销此同意。 |
免疫接种史 / Immunization History
| English | 中文 | English — Help | 中文 — Help |
|---|---|---|---|
| Immunization Records Provided | 已提供疫苗接种记录 | Check 'Records attached' if you are submitting a copy of the child's immunization records with this form. Records may include the yellow WIC immunization card, a printout from a previous provider's patient portal, or school immunization records. Your provider will review these against the current CDC-recommended immunization schedule. The CDC publishes the recommended immunization schedule at cdc.gov — your provider will compare your child's records against this schedule. | 如果您随此表格提交儿童疫苗接种记录的副本，请勾选'记录已附上'。记录可包括WIC黄色疫苗接种卡、来自上一家医疗机构患者门户的打印件或学校疫苗接种记录。您的医疗提供者将根据当前CDC推荐的免疫接种时间表审查这些记录。CDC在cdc.gov上发布推荐的免疫接种时间表——您的医疗提供者将根据此时间表比对您孩子的记录。 |
| Up to Date per CDC Schedule (Yes / No / Unsure) | 符合CDC时间表（是/否/不确定） | A simple checkbox or radio selection. If unsure, select 'Unsure' — your provider will review the attached records and advise on any gaps. Missing doses can often be caught up; your provider will discuss the right schedule for your child's age and health history. | 简单的复选框或单选选项。如果不确定，请选择'不确定'——您的医疗提供者将查看附上的记录并就任何缺口提供建议。缺失的剂次通常可以补上；您的医疗提供者将讨论适合您孩子年龄和健康史的正确时间表。 |
Sources
Last reviewed: September 2026