• Patient Health History

    Please complete this form for each patient.
  • Patient's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Race*
  • Ethnicity*
  • Preferred Language*

  • Newborns and Children Under 1 Year of Age

  • Gestational Age
  • Birth Hospital
  • Any issues during pregnancy including abnormal screenings?
  • Any issues after delivery?

  • Medication Information

  • Medical History

  • Current or Previous Medical Conditions
  • Past Surgical History
  • Family Medical History: Please indicate any family history of the following conditions. If a condition is not listed, please describe this below.
    Rows

  • Social History

  • Does your child attend daycare/school?
  • Do you have pets in the home?
  • Does your child have any secondhand smoke exposure (including vaping and marijuana)?
  • Is there a history of abuse, neglect or CPS involvement?

  • Additional Part of the Patient's Care Team

  • If your child sees a dentist, who does he/she see?
  • Should be Empty: