Health History

Patient Name*

DOB*

Gender*

Male
Female

Parent/Guardian 1*

Relationship*

Parent/Guardian 2

Relationship

Primary Care Physician

School

Birth Weight*

Gestational Week*

Full Term*

Yes
No

Delivery*

Vaginal
C-Section

Vaccinations Current*

Yes
No

Drug Allergies/Reactions

Current Medications

Problems During Pregnancy

Problems During Delivery

Past Medical History

Check all that apply.

Q1A

Q1B

Other

Hospitalizations

Surgeries

Family History

Check all that apply.

Q2A

Q2B

Muscular Disorders
Cancer
Lung Disease

Other

Signature

Parent/Guardian Name*

Relationship*

Parent/Guardian Signature*

Hidden

Date

Email

This field is for validation purposes and should be left unchanged.

Past Medical History

Family History

Signature

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Office Hours

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After-hours Care

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