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FAQs
Contact Us
How to find us
Fees
Products
Blog
The Team
Testimonials
Pediatric Patient Form
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Pediatric Patient Form
PATIENT INFORMATION
Patient Name (required)
Address
Home Phone
Mobile Phone
Email
Sex
female
male
Age
Birthday
Mother's Name
Mother's Occupation
Mother's Phone
Mother's Email
Father's Name
Father's Occupation
Father's Phone
Father's Email
Who may we thank for referring you to us?
IN CASE OF EMERGENCY, CONTACT
Name
Relationship
Contact Number
HOW CAN WE HELP YOUR CHILD?
Wellness Checkup
Other
If Other please describe:
If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?
No
Yes
Please describe:
PREGNANCY HISTORY
Did you experience any complications during your pregnancy? (check all that apply)
Back/Other Pain
Gestational Diabetes
Pre/Eclampsia
Pre-Term
Strep B
Fatigue
Swelling
Nausea/Vomiting
Other:
BIRTH HISTORY
Type of birth (check all that apply)
Home
Epidural
Normal / Vaginal
Breech
Hospital
Birth Centre
Caesarean
Scheduled/Induced
Problems during labour / delivery?
Jaundice
Meconium
Antibiotics
Respiratory Distress
Congenital Anomalies
Extended Hospitalization
Failure to Thrive
Other?
GROWTH & DEVELOPMENT
Infant Feeding
Breast
Bottle
Formula
Number of hours of sleep each night:
Quality of sleep:
At what age did the child:
Respond to sound:
Stand:
Crawl:
Sit unsupported:
Hold head up:
Walk unsupported:
CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS
Has your child had (check all that apply)?:
Chicken Pox
Measles
Mumps
Rubella
Rubeola
Pertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:
Allergies
Anaemia
Asthma
Arm Problems
Back Aches
Bed Wetting
Broken Bones
Behavioural Problems
Chronic Ear Aches
Colds/Flu
Colic
Convulsions/Seizures
Delayed Speech
Diabetes
Dizziness
Digestive Issues (constipation/diarrhoea)
Fainting
Headaches
Heart Trouble
Hyperactivity
Hypertension
Joint Problems
Juvenile Rheumatoid Arthritis
Leg Problems
Neck Problems
Neuritis
Orthopaedic Problems
Paralysis
Poor Appetite
Ruptures/Hernias
Sinus Trouble
Tuberculosis
Walking Problems
Have you vaccinated your child?
No
Yes
As scheduled
Delayed Schedule
ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY
ALLERGIES (list)
MEDICATIONS (list)
SURGERIES (list)
FAMILY HISTORY (list)
SIBLINGS
How many children do you have?
Number of pregnancies
Children's Ages
Children's health concerns:
Are you currently pregnant?
No
Yes
If you are currently pregnant what is your due date?
Health concerns regarding this pregnancy?
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