PEDIATRIC INFORMATION FORM (BIRTH-12 YRS)
Patient Information Name:
Date:
Sex: ☐ Male ☐ Female
Date of birth:
Age:
Parent/Guardian’s name(s): Street address: City: State:
Zip code:
Email address: Home phone:
Cell phone:
Insurance Provider/ID#: Whom may we thank for referring you? Prenatal History Any complications during pregnancy: Any alcohol? Yes/No
Any tobacco? Yes/No
Any vaccines/medication? Yes/No
Reason for vaccines/medication: Illness/infections during pregnancy: Ultrasounds or other testing: What things were done to stay healthy during pregnancy?
Birth History Place of birth: Provider: Type of birth:
☐ Home ☐ Midwife ☐ Vaginal
☐ Birthing Center ☐ OB-Gyn ☐ Cesarean
☐ Hospital ☐ Other
Were pain medications used? Yes/No Pitocin used? Yes/No Was labor induced? Yes/No If yes, why? Birth trauma? ☐ Doctor assisted ☐ Twisting/Pulling ☐ Vacuum Extraction ☐ Forceps APGAR score if known: Did your child have a misshaped skull/head? Yes/No Did you breast-feed your child? Yes/No How long? Any food allergies: Has your child been vaccinated? Yes/No Reason: ☐ Informed decision ☐ Recommended ☐ Didn’t know I had a choice Did your child have any negative reaction to the vaccines? Yes/No If yes, were they reported? Yes/No Has your child ever had any surgeries? Yes/No If yes, elaborate:
(See Reverse)
Made with FlippingBook - professional solution for displaying marketing and sales documents online