Fill out the following
information (bold fields are mandatory) and click 'Submit'.
Please provide
us with information about the yourself (the person filling out this form): |
| First Name: |
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| Last Name: |
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| Address 1: |
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| Address 2: |
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| City: |
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| State/Province: |
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| Zip Code: |
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| Email Address: |
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| Verify Email: |
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| Home Phone: |
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| Business Phone: |
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| Fax: |
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| Information about the child: |
| First Name: |
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| Middle Name: |
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| Last Name: |
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| Date of Birth: |
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| Information about the child's parents: |
| Mother's Full Name: |
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| Mother's Occupation: |
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| Father's Full Name: |
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| Father's Occupation: |
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| If adults in the household work outside the home, what child care arrangements are made for this child?: |
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| Pregnancy and Birth: |
| Mother's age at child's birth: |
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Did mother have any illness during pregnancy?: |
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Did she take any medications other than vitamins and iron?: |
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Was the baby: |
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Vaginal Delivery or C-Section?: |
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| What was the baby's birth weight?: |
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Did the baby have any trouble starting to breathe?: |
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Did the baby have any trouble while in the hospital? (Jaundice, infections, other?): |
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| If yes, what kind?: |
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| Past Medical History: |
| Where has your child gone for well checkups until now?: |
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| Date of last checkup: |
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| Date of last dental checkup: |
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Has your child had allergic reactions to any medications, foods or insect bites?: |
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Has your child had any allergic reactions to any immunizations?: |
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Any hospitalizations other than birth?: |
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| If yes, for what?: |
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Any serious injuries?: |
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| If yes, what injuries?: |
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Any medications taken regularly?: |
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| If yes, which ones?: |
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Any prior surgeries?: |
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| If yes, what kind?: |
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| Family History: |
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Are the child's parents both in good health?: |
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| List age, sex and general health of patient's brothers and sisters: |
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Have any of your children died?: |
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| Feeding and Nutrition: |
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Is your child's appetite usually good?: |
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Is your child's appetite good now?: |
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Were there severe colic or any unusual feeding problems during the first 3 month?: |
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Do any foods disagree with your child?: |
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For the first 6 months, was your child breast fed or bottle fed?: |
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| If still on formula, which one do you use?: |
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Does your child take vitamins?: |
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| Review of Systems: |
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Has your child had frequent ear infections?: |
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Has your child had any problems with teeth?: |
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Does your child have frequent colds or sore throats?: |
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Is there asthma, pneumonia or recurrent cough?: |
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Any problems with urination?: |
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Any problems with diarrhea or constipation?: |
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Have there been any convulsions or other problems with the nervous system?: |
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Any eczema, hives or other skin conditions?: |
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Has your child ever been anemic?: |
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Has your child had any of the following?: |
Nail Biting
Thumb Sucking
Bedwetting
Problems with Toilet Training
Bad Temper
Hyperactivity
Nightmares
Speech Problems
Problems with Discipline
Other behavior problems
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| Please list any other problems: |
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| Developmental History: |
| At what age did your child sit alone?: |
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| At what age did your child walk alone?: |
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Did your child say words by the time he/she was 1/2 years old?: |
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| How does this child compare to others of the same age?: |
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Does your child have trouble sleeping?: |
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| What grade is he/she in?: |
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Has your child had any trouble in school?: |
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Has your child had to repeat a grade?: |
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Does your child get along with other children?: |
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| Safety/Environment: |
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Do you live in a: |
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| If 'other dwelling,' please specify: |
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Do you know the hottest temperature of the water in the pipes?: |
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Is there a smoke alarm on each floor in the house?: |
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Does your child always use a car seat/seat belt when riding in a car?: |
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Are there any smokers in the household?: |
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Aare there any problems with the condition of your home? (Peeling paint, insects, rats or mice?): |
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Does your child always wear a helmet when riding his/her bicycle?: |
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Are there any guns in the home?: |
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Do you have a record of immunizations?: |
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| Family History: |
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Have any family members had any of the following?: |
Deafness
Nasal Allergies
Asthma
Tuberculosis
Heart Disease (before age 50)
High Blood Pressure (before age 50)
High Cholesterol
Anemia
Bleeding Disorder
Liver Disease
Kidney Disease
Diabetes (before age 50)
Bed-Wetting (after age 10)
Epilepsy or Convulsions
Alcohol Abuse
Drug Abuse
Mental Illness (depression, anxiety, etc.)
Mental Retardation
Immune Problems, HIV, AIDS
Thyroid Problems
Inherited Illness
Cancer
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| If you checked any of the above, please indicate who (relation to child) and add any notes or comments: |
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| Additional family history: |
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