| Name_______________________________ |
Birthdates_____/_____/_____ |
Marital Status of Biological Parents
M S D W |
| How Did You Hear of our
Practice?___________________________________________________________ |
| Pediatric Information: |
|
|
| Birth History: Vaginal / C-Section
Delivery? ____ Full Term? _____Yes _____No |
| Breast Fed? _____Yes _____No Till Age _____ |
| Any Problems During Pregnancy, Delivery, Or in Nursery?
(e.g. Breathing Trouble, Jaundice, C-Section, Etc. |
|
______________________________________________________________________________________ |
| Is the Child Taking Any of the Following Regularly: |
| |
Aspirin |
Antibiotics |
| |
Cough / Cold Medicine |
Steroids |
| |
Laxatives |
Vitamins |
| |
Allergy Injections |
Ritalin |
| |
Allergy Pills |
|
| |
Diet Pills |
|
|
| Write in Any Surgeries or
Operations_________________________________________________________ |
|
_____________________________________________________________________________________ |
| List Any Allergies to
Medications____________________________________________________________ |
| Write in Any Reasons for
Hospitalization_______________________________________________________ |
| Do You Know of Any Blood Relative Who Has Had: |
| |
Diabetes |
Heart Attack |
Arthritis |
| |
Cancer |
Leukemia |
Kidney Disease |
| |
Epilepsy |
Nervous Breakdown |
Bleeding Tendency |
| |
Asthma |
Goiter |
|
|
| Primary Care Taker of
Child_______________________________________________________________ |
| Are There Any Smokers in the
House?_______________________________________________________ |
| Other Children in the
House?______________________________________________________________ |
| Child's Caffeine
Consumption______________________________________________________________ |
| Pets in the
House?______________________________________________________________________ |
| Is Child Active in
Sports?_________________________________________________________________ |
| Generally How Are Child's Grades in
School?_________________________________________________ |
| Any Concerns About Developmental
Progress?________________________________________________ |
|
____________________________________________________________________________________ |