Pediatric Registration

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General Information
Please note that laboratory tests and some preventive health care packages may not be covered by your insurance. If you are unsure if your medical treatment is covered by your insurance, please ask a member of staff for clarification.
Pediatric Medical Questionnaire
Past Medical History

Does your child now or has ever had any of the following?

Current Medication
Food or any not known allergies
Patient's birth History
Number of
Developmental History

If your child has developmental problem, at what age did they occur?

Please indicate the approximate age in months for the following milestones (example: walking 14months)

Sitting up
Dryness at night
Crawl
First words (Mommy, car)
Pulled to stand
Spoken clearly
Walked alone
Lost language
Potty trained
Lost eye contact
Family Mental-Physical History

Any family history of

Speech-Language History

Provide the approximate age at which the child began to do for the following

Ask simple questions (e.g. what’s this? Where is daddy?)
Say single words (e.g. no, mom, dog)
Combine two words (e.g. eat cookie, me go, mommy)
Engage in a conversation
Name things (e.g. eye, cat, car)
Educational History
Pain Injury History
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2
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10
No Pain
Worst Pain in My Life

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