NEW Patient History Form

Union Mill Pediatrics, P.C.

Your child’s name:

Date of Birth:

Birth History:

NAME OF OB

(If under 1 year old) Weight of child at birth?

Type of delivery?

vaginal c-section

Complications?

Child’s History:

Medications currently taking:

Hospitalizations/Surgeries:

Special equipment of services required :

Dentist?

Yes No

Ophthalmologist?

Yes No

Specialist (if involved, please state reason)

Social History

Patient lives with:

Parents married/divorced?

Married Divorced Separated Other

Step parent?

Y N

Foster parent?

Y N

PETS

YES NO

Smokers?

Yes No

If Yes, where do you smoke?

inside outside of house both

Does you child attend School or Daycare?

Yes No

House Built before 1968?

Yes No

Recent foreign travel longer than three months?

Yes No

FAMILY HISTORY

If Other is selected, please specify:

If Cancer is selected, please list all affected relatives:

NAME OF PERSON FILLING OUT FORM

Todays DATE

Your information will be encrypted.

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