New Patient History

New Patient History

MM slash DD slash YYYY
Patient Name(Required)
MM slash DD slash YYYY

Problems

Are there any potential stress issues in your home?
Select all that apply:(Required)

Allergies

Please list your child’s allergies (if any):
Medications
Foods
Seasonal
Pets
Other

Medications

Does your child take any medications? (please include vitamins and herbal)(Required)
If yes, please list all below:

Immunizations

Has your child received immunizations?(Required)
If child is behind, please list what shots and why below:

Past Medical History

Please check all that apply:(Required)

Social History

Please list the names, sex and age of siblings. Also, if full, half, step or adoptive
Name
Sex
Age
Relation
 
Do you have pets in the home?(Required)
If yes, please list all pets:
 
Does anyone smoke in the home?(Required)
* Please select all that apply.
Guns in the home?(Required)
If yes, are guns locked/secured?
If yes, is the gun stored separately from ammunition?

Home Life

What kind of home does the child live in?
Was your home built before 1970?(Required)
If yes, have you done any major remodeling to cover or remove old lead paint?
Do parents work? If yes, please list occupation.(Required)
Occupation(s)
Father/Guardian
Mother/Guardian
 
Does your home have any of the following:

Childcare/Education

Does your child go to daycare?(Required)
If yes, is the daycare provider a:
Does your child go to school?(Required)
If yes, please list school name and grade. (*If child is homeschooled please list under school name.)
School Name
Grade
 

Perinatal History

Was the child premature?(Required)
Any problems during pregnancy?(Required)
How was baby delivered?(Required)
Did baby need any special help after delivery?(Required)
If yes, please check all that apply: