• AUBREY K. EWING, PH.D. & ASSOCIATES, P.A.                      
    1230 So. Federal Hwy, Boynton Beach, FL 33435
    561.742.7122 | Fax 561.742.7452
    Email: contact@drewingonline.com

  • CHILDHOOD HISTORY FORM

    Please answer all of the following questions to the best of your knowledge.  The  information you provide is essential in helping your doctor formulate a diagnostic impression of and treatment plan for your child.  The answers you provide on this form are considered protected health information (PHI) and will be kept secure and confidential as required by HIPAA regulations.

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  • INFORMATION ABOUT CHILD'S PARENTS

  • INFORMATION ABOUT SIBLINGS

  • INFORMATION ABOUT PREGNANCY


  • INFORMATION ABOUT DELIVERY


  • CHILD'S DEVELOPMENT - INFANCY PERIOD

  • PRESENT HEALTH/MEDICAL STATUS

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  • COORDINATION

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  • COMPREHENSION AND UNDERSTANDING

  • EDUCATIONAL (SCHOOL) HISTORY

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  • BEHAVIOR AT HOME

  • INTERESTS AND ACCOMPLISHMENTS

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