Primary Problems
If it applies, please draw in the pictures below where this has bothered you or your child
Health Providers
Add Health Provider
Other medical conditions/diagnoses
Add Medical Condition
Please list all medications, supplements, herbs, remedies and vitamins that taken:
Add Medication
Please list all allergies and intolerances
Add Allergy/Intolerance
BIRTH HISTORY
Add Hospitalization
Father
Mother
Add Sibling
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