Your child's health is of utmost importance to us. Please fill out this form as completely and accurately as you can. If you are unsure of how to answer a certain item, just circle the item and we will be happy to discuss it with you. All information will be treated confidentially.
Please check if child has ever had any of the following:
How often does your child eat the following:
Is there fluoride in your water?
Please check whether or not your child has been given the following immunizations. If yes, please fill in the date(s) given.
Please give the following information about your child's immediate family:
Please check conditions that any of the child's blood relatives (including parents and siblings) have had and the relationship to the child:
During the pregnancy which conditions did you have? Please check all that apply:
DELIVERY - Please check all that apply:
INFANT HEALTH
INFANT HEALTH PROBLEMS - Please check and describe:
FEEDING
DEVELOPMENTAL - Please note age at which your child:
Please explain any problems or concerns you have about your child in any of the following areas:
Do you suspect that your child is involved with:
Have you noticed any of the following warning signs of drug abuse:
To the best of my knowledge, the above information is complete and correct. I understand that reporting incomplete or inaccurate information can be dangerous to my child's health. I understand that I am solely responsible for any errors or omissions that I may have made in the completion of this form. I understand that it is my responsibility to inform my doctor if my minor child ever has a change in health.
