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MaleFemale

HOUSEHOLD

Please list all those living in the child’s house

BIRTH HISTORY

lbs oz.

YesNoEarlyLate

YesNo

YesNo

YesNo

VaginalCesarean?

YesNo

BreastBottle?

YesNo

GENERAL

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

DEVELOPMENT

YesNo

YesNo

YesNo

If your child is in school:

FAMILY HISTORY

Have any family members had the following:

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

PAST HISTORY

Does your child have or has he/she ever had:

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

OTHER MEDICAL SPECIALISTS

Please list any other medical specialists that your child sees

AUTHORIZATION FOR TREATMENT

In the event that I, (name of parent/guardian) am unable to accompany my child/children listed above, I authorize the following individual(s) to give permission for minor treatments in my absence:

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