Pediatric History Questionnaire

Please correct the errors described below.


Please list all those living in the child’s home

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Pregnancy & Birth

During pregnancy did mother:

General (If applicable)


At what age did your child:

Dental History

Home Environment

Family History

Have any family members had the following medical condition?

Past History (if applicable)

Does your child have or has he/she ever had:

Review of Organ Systems

Please check any symptoms your child is experiencing. If your child has more than one symptom on a line, check the relevant ones.

I hereby certify that the information given on this form is accurate and true to the best of my knowledge.

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