The following comprehensive form will require you to share with us your child's medical and developmental history. This will enable us to prepare for your child's first visit and maximize your time with us.
AgeYears Please Select123456789101112131415161718192021 Months Please Select1234567891011
Birth weight: Please Select12345678910 lbs Please Select123456789101112131415 oz.Apgars: Please Select12345678910 Pregnancy: Full term Premature IVF
LABOR: Total length of labor:total length of labor Induced birth?Yes NoBreech presentation?Yes No Delivery: Vaginal Cesarean Forceps Anesthesia (other than epidural)
Allergies Yes No Type
Ear infections? Yes No Frequency
Has child had high fevers? Yes No Seizures? Yes No Frequency: General health at present Good Fair Poor
My child is in school/day care from the hours of : Please Select7 am8 am9 am 10 am11 am12 pm 1 pm2 pm 3 pm 4 pm 5 pm6 pm7 pm to Please Select7 am8 am9 am 10 am11 am12 pm 1 pm2 pm 3 pm 4 pm 5 pm6 pm7 pm
Does your child have a “best friend”? Yes No Older or younger? Older Younger Same age
Does your child take a bath? Yes No Shower? Yes NoDoes he/she enjoy it? Yes No Is he/she sensitive to the temperature of the water? Yes No
How much do you understand of your child’s speech? Please Select10%25%33%50%66%75%90%100% How much do others not familiar with your child? Please Select10%25%33%50%66%75%90%100%
By signing your name above, you agree that your digital signature, can be used as your actual signature.