• Patient History

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What kind of home does the child live in?*
  • Was your home built before 1970?*
  • Does the child's father work?*
  • Does the child's mother work?*
  • Does your home have any of the following?*
  • Does your child go to daycare?*
  • Which type of daycare does your child attend?
  • Does your child go to school?*

  • Perinatal History

  • Was the child premature?*
  • Any problems during the pregnancy?*
  • How was the child delivered?*
  • Any problems during delivery?*
  • Did the child need any special help after delivery?*
  • If yes, what?

  • Past Medical History

  • Please check all that apply for the child:*
  • Has your child ever been hospitalized overnight since birth?*
  • Has your child ever had any surgeries?*

  • Social History

  • Who does the child with?*
  • Parents are:*
  • Does the child have siblings?*
  • Do you have pets in the home?*
  • Does anyone smoke in the home?*
  • Do you have guns in the home?*
  • If yes, are the guns locked/secured?
  • If yes, are the guns stored separately from ammunition?
  • Are there any potential stress issues in your home? (check all that apply)*
  • Does your child have any allergies?*
  • Dos your child take any medications? (Please include vitamins & herbal medicines))*
  • Has your child received immunizations?*
  • Should be Empty: