Pediatric Associates of Denham Springs

PLEASE FILL IN ALL INFORMATION

Patient Name:

Phone:

Date:

Address

Email Address

Pharmacy

DOB

In order to be ready for your chid's visit, we'd like to know:

1. Has your child been to the emergency room (ER) since your last visit?

Yes No

If Yes, when and why?

What happened? What did they tell you to do?

2. Has your child been in the hospital since your last visit

Yes No

If Yes, when and where?

Why?

3. Has your child seen any specialist since your last visit?

Yes No

When and where?

Why

4. Has your child had any blood work or x-ray done since your last visit?

Yes No

When and where?

5. Are there any forms or letters you will need us to fill out today?

Yes No

6. What medications does your child take?

7.Does you child have any drug allergies?

Yes No

If Yes, Please list drug allergies

8. What are our top areas of concern or topics that you want to talk about at this visit?

9. What is your name and relationship to the patient?