Health History

Please correct the errors described below.

Please list all People in your household

Add Other Person

Birth History

During Pregnancy did the mother:


Family History

Have any of the child’s blood relatives had the following diseases:

Past Medical History

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Please list any hospitalizations, operations, serious illnesses, or accidents:

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Has your child had any problems with the following?

Is your child currently seeing any specialists: (Example: pulmonologist, behavioral health, nutritionist, etc…)

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To be Completed by Teenage Patients

For Women

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