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Gracielle and Danny


Please type all the required information in the spaces provided below:

PATIENT INFORMATION

Name / Male or Female

Street Address
City, State, Zip Code
Date of Birth
Home Phone #
Father's Name/Marital Status
Father's Work/Cell Phone #
Mother's Name/Marital Status
Mother's Work/Cell Phone #
Other Information

      BIRTH HISTORY

Length/Weight/Head Circumf.
Apgar Score
Full Term/Premature_Weeks
Vaginal Delivery/C-Section
Any Complications

Breastfeeding or Bottlefeeding

Type of Formula

Vitamins/Medicine

Hospital

Obstetrician's Name

MEDICAL HISTORY
Childhood Disease/Date
(i.e. chicken pox, mumps, etc)
Allergies 
Medications/Treatment
Siblings & Age
FAMILY HISTORY

Please indicate "YES" in the space provided if the patient has any of these conditions. Specify: "P" (patient), "F/FS" (father/father's side), "M/MS" (mother/mother's side)

Healthy
Asthma
Heart Disease
Diabetes
Hypertension
Cancer 
Alcoholism
Smoker
Other Conditions
 
SCHOOL INFORMATION
Name of School
Grade Level
Activities
Sports
Medications taken in school
Special Education needed

I, hereby, certify that the information I provided above is correct.

Date/Time
Print Patient's Name
Print Parent/Guardian's Name
Signature (In Person)  

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  Please come 5 minutes earlier before your appointment to sign any necessary
  forms. Thank you.
 


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