Patient's Date of Birth*

Sex

Do you consider your child to be in good health?

Has your child ever been hospitalized?

Is your child allergic to medicines, drugs, or food?

Does your child have any special care needs?

Delivery

Any complications during or after birth?

Did the baby go to NICU?

Was the mother positive to any of the following labs?

After birth, did the baby received any of the following?

During pregnancy, did the mother:

Has your child ever had any of the following problems?

Has your child had any surgeries?

Child's current living situation?

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