PEDIATRIC INFORMATION FORM (13-17 YRS)
Patient Information
Name: __ Date: 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? Patient History How would you describe the pregnancy? ☐ Normal ☐ Somewhat difficult ☐ Very difficult How would you describe infancy? ☐ Normal ☐ Somewhat difficult ☐ Very difficult How would you describe childhood? ☐ Normal ☐ Somewhat difficult ☐ Very difficult If you answered anything but normal, why?
How would you describe overall physical development? ☐ Above average ☐ Typical How would you describe overall mental development? ☐ Above average ☐ Typical
☐ Behind schedule
☐ Behind schedule
Any childhood illnesses/diseases? Any surgeries? Any accidents? Has your child been vaccinated? Yes/No If yes, which ones? 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 been on antibiotics? Yes/No If yes, how often and what purpose? Is your child currently taking any medication? Yes/No If yes, how often and what purpose? Is your child currently taking any vitamins? Yes/No If yes, how often and what purpose? Is there anything significant in patient’s health history the Doctor should know?
(See Reverse)
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