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Pediatric Patient Form

PATIENT INFORMATION

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IN CASE OF EMERGENCY, CONTACT

HOW CAN WE HELP YOUR CHILD?

Wellness CheckupOther
Has your child been treated on an emergency basis? NoYes

PREGNANCY HISTORY

Did you experience any complications during your pregnancy? (check all that apply)
Back/Other PainGestational DiabetesPre/EclampsiaPre-TermStrep BFatigueSwellingNauseau/Vomitting

BIRTH HISTORY

Type of birth (check all that apply)
HomeEpiduralNormal / VaginalBreechHospitalBirth CentreCaesareanScheduled/Induced

JaundiceMeconiumAntibioticsRespiratory DistressCongenital AnomaliesExtended HospitalizationFailure to Thrive

GROWTH & DEVELOPMENT

Infant Feeding BreastBottleFormula
At what age did the child:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

Has your child ever suffered from (check all that apply)?:
AllergiesAnaemiaAsthmaArm ProblemsBack AchesBed WettingBroken BonesBehavioural ProblemsChronic Ear AchesColds/FluColicConvulsions/SeizuresDelayed SpeechDiabetesDizzinessDigestive Issues (constipation/diarrhoea)FaintingHeadachesHeart TroubleHyperactivityHypertensionJoint ProblemsJuvenile Rheumatoid ArthritisLeg ProblemsNeck ProblemsNeuritisOrthopaedic ProblemsParalysisPoor AppetiteRuptures/HerniasSinus TroubleTuberculosisWalking Problems
Have you vaccinated your child?
NoYesAs scheduledDelayed Schedule

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY

 

SIBLINGS

Are you currently pregnant? NoYes