This questionnaire gives you a chance to tell us about your child. We want to know about your concerns and worries so that we can try to help. Knowing about things like your child’s health, past experiences, and family history can help us help your child. The questionnaire should be completed by the person who takes care of the child most of the time. There is no right or wrong answer. Answer each question to the best of your ability. If you do not know the answer, make notes of what you do know. We need this form before we can schedule your child’s appointment. All information is kept strictly confidential.
What medicines, vitamins, and nutrition supplements does your child take each day?