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Initial History Questionnaire

Please fill out and submit online to save time when you visit our office for the first time

GENERAL

Do you consider your child to be in good health?
Does your child have any special care needs?
Has your child ever been hospitalized?
Is your child allergic to medicines, drugs, or food?

BIRTH HISTORY

During pregnancy, did the mother:
Any complications during or after birth?
Was the mother positive to any of the following labs?
Did the baby go to NICU?
After birth, did the baby received any of the following?

PAST MEDICAL HISTORY

ENT
Pulmonary
Gastrointestinal

Has your child ever had any of the following problems?

Hematology
Eyes
Heart
Urology
Neuro
Endocrine
Skin
Gynecology
Surgery
Behavior
Orthopedics

SOCIAL AND FAMILY HISTORY

Child's current living situation?
Family history 3
Family history 2
Family history 1

Have any of your child's parents, grandparents, aunts, uncles, brothers or sisters ever had any of the following conditions?

Thanks for submitting!

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