If you do not remember the answer to a certain question, please make a reasonable estimate or leave blank. Someone will go over the completed form with you. Please add at your next visit any information which you may have at home or elsewhere. Certain items will not apply to your age child; simply leave blank. The form will be returned to you periodically for updating. Please attempt to obtain any old immunization records before being seen. You should try to be as accurate as possible.
It is against the child's best interest to make him/her "look good" on the form. If your child "was developmentally slow", "relates poorly to other children", "wets the bed at age 12 years", or "takes drugs", then so state. This form, like the entire medical record, will remain confidential and not be released to anyone without your approval. It is required that the child's mother or father be present for the first visit. Other family members or relatives are often unable to provide full information regarding past medical history.
It is important that you bring the completed form with you for the initial visit.
You can download and print this form by clicking here:
New Patient History Form