New Patient History Form

Release of Health Information/Records

Name of Child

Date of Birth

Does your child have any ongoing medical problems?

Yes No

If yes, please list

Specialist(s), if any

Does your child have any past medical problems which he/she's outgrown?

Yes No

Has your child spent the night in the hospital?

Yes No

Any surgeries?

Yes No

Please list with approximate date(s)

Short text field

Is your child on medications (include prescription and over-the-counter)?

Yes No

If yes, please list along with doses

Pharmacy

Does your child have any allergies?

Yes No

If yes, please list

If other, please specify

Who lives in the house with your child?

Do you own any pets?

Yes No

If yes, type of pet

Are there any smokers in the home?

Yes No

If yes, please specify

Inside Outside

Do you have any water near your home?

Yes No

If yes, please choose

Private Pool Community Pool Lake Canal Ocean

If you have a private pool, do you have a pool fence?

Yes No

If your child is 4 years or older, does he/she know how to swim?

Yes No

Does you child attend a daycare or school?

Yes No

Name of the daycare or school

Grade/year

Does your child have any special needs in school or daycare?

Yes No

If so, please list

Do you have any questions/concerns you want to address today?

Do you have any prayer requests?