Patient Name
*
Birthdate
*
/
Month
/
Day
Year
Date
Form completed by
*
Please list ALL those living in the child's home (other than the patient)
Name
blanks
. Relationship to the patient
blank
. Birth Date
Date
Name
blanks
. Relationship to the patient
blank
. Birth Date
Date
Name
blanks
. Relationship to the patient
blank
. Birth Date
Date
Name
blanks
. Relationship to the patient
blank
. Birth Date
Date
Name
blanks
. Relationship to the patient
blank
. Birth Date
Date
Are there siblings not listed? If so, please list their name(s), age(s), and where they live
If parents are not living together, or if the child does not live with the parents, what is the child's custody status?
If one or both parents are not living in the home, how often does he/she see the parent/parents not in the home?
Have any of your family members had the following:
Deafness
*
Yes
No
Who?
Additional Information:
Nasal Allergies
*
Yes
No
Who?
Additional Information:
Asthma
*
Yes
No
Who?
Additional Information:
Tuberculosis
*
Yes
No
Who?
Additional Information:
Heart Disease before 50 years old
*
Yes
No
Who?
Additional Information:
High Blood Pressure BEFORE 50 years old
*
Yes
No
Who?
Additional Information:
High Cholesterol
*
Yes
No
Who?
Additional Information:
Anemia
*
Yes
No
Who?
Additional information:
Bleeding Disorder
*
Yes
No
Who?
Additional Information:
Liver Disease
*
Yes
No
Who?
Additional Information:
Kidney Disease
*
Yes
No
Who?
Additional Information:
Diabetes BEFORE 50 years old
*
Yes
No
Who?
Additional Information:
Bed-Wetting (AFTER 10 years old
*
Yes
No
Who?
Additional Information:
Epilepsy or convulsions
*
Yes
No
Who?
Additional Information:
Alcohol Abuse
*
Yes
No
Who?
Additional Information:
Drug Abuse
*
Yes
No
Who?
Additional Information:
Mental Illness
*
Yes
No
Who?
Additional Information:
Intellectual Disability
*
Yes
No
Who?
Additional Information:
Immune Problems, HIV or AIDS
*
Yes
No
Who?
Additional Information:
Additional Family History
*
Yes
No
Who?
Additional Information:
Does your child have, or have they ever had:
Chicken Pox
*
Yes
No
Additional information:
Frequent ear infections
*
Yes
No
Additional information:
Problems with ears or hearing
*
Yes
No
Additional information:
Nasal Allergies
*
Yes
No
Additional information:
Problems with eyes or vision
*
Yes
No
Additional information:
Asthma, bronchitis, bronchiolitis, or pneumonia
*
Yes
No
Additional information:
Heart problems or heart murmur
*
Yes
No
Additional information:
Anemia or bleeding problem
*
Yes
No
Additional information:
Blood transfusion
*
Yes
No
Additional information:
Frequent abdominal pain
*
Yes
No
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Additional information:
constipation requiring doctor visits
*
Yes
No
Additional information:
bladder or kidney infections
*
Yes
No
Additional information:
bedwetting after 5 years old
*
Yes
No
Additional information:
(For girls) Has she started her menstrual periods
Yes
No
Additional information:
(For girls) Are there problems with her periods
Yes
No
Additional information:
Any chronic or recurrent skin problems (acne, eczema, etc)
*
Yes
No
Additional information:
Frequent Headaches
*
Yes
No
Additional information:
Convulsions or other neurologic problems
*
Yes
No
Additional information:
Diabetes
*
Yes
No
Additional information:
Thyroid or other endocrine problems
*
Yes
No
Additional information:
Use alcohol, drugs, or cigarettes
*
Yes
No
Additional information:
Any other significant problems
*
Yes
No
Additional information:
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