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Available Forms

Behavioral intake (up to 7 years old)

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.

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