Parent / Guardian Name: * Address: * Phone Number: * Email: * Marital Status * Child First Name * Child Last Name * Who does the patient live with? * Birthday * Race * Smoker in the home? *

Past Medical History

List all Diagnosed Issues *

Past Operations & Procedures: (Age or Date)

Tonsils Appendix Ear Tubes OTHER HOSPITALIZATIONS / ACCIDENTS / INJURIES

Current Medications

Prescriptions & over the counter *

Allergies & Reactions

List any and all known allergies: *

Birth History

Length of pregnancy Type of delivery Weight Length Type of feeding Brand of formula Complications during pregnancy Problems in nursery

Development History

Rollover (Age) Crawl Toilet Training Sit Alone Walk Alone Speak single words Make sentences Did your child have any of the following problems during the first few months of life?

Gynecologic History (If Applicable)

Are you menstruating? Do you use birth control? Are you sexually active?

Social History (Habits)

Does the child attend daycare? Where do you go to school? What grade are you in? Do you have any hobbies / sports? Pets in the home? Do you use Fluoride in the water? Do you have dietary restrictions? How fequently do you exercise? Do you wear a seat belt? Do you consume caffeine? Do you drink alcohol? Do you use tobacco products? Do you use illegal drugs Have you traveled outside the US?

FAMILY HISTORY (If Known)

Father Age Health Problems: Mother Age Health Problems: Sister Age Health Problems: Brother Age Health Problems: Children Age Health Problems: Grandparents health history?