Behavioral Intake for Younger Kids
(e.g. Neurologist, Psychiatrist, Counselor, Immunologist) Include contact numers
Family Unit
Perinatal History
(weeks)
(if known)
Infancy History
Allergy History
Include hormones, psychiatric/behavioral meds, infusions like IVIG or steroids, topical creams and supplements.
Include hormones, psychiatric/behavioral meds, infusions like IVIG or steroids, topical creams and supplements.
Immunization Reactions
Infections and Triggering Factors
Course
Onset and first month
(nearest possible)
(Hours/Days)
e.g., starting school/family changes etc
Description of Course
Family History
Please select if any primary, secondary, or more distant relative has ever had a diagnosis any of the following.
Primary= Parent or sibling
Secondary = Grandparent, Aunt/Uncle or half-sibling
More distant= Cousin, great grandparent, etc.
Please press submit to send this entire form to Ideal Pediatrics. Please allow 2-3 days for Dr. Cangas to review. we will contact you to discuss scheduling at that time. Thank you.