PEDIATRIC HEALTH HISTORY by MAUUT0

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									                       PEDIATRIC HEALTH HISTORY

Name: ______________________ DOB: _____       Previous Physician: ______________

School: _____________________ Grade: ____      Home Phone: __________________

Current Medical Problems: ________________________________________________

Past Medical Problems: ___________________________________________________

Allergies: ______________________________________________________________


                Name                 DOB            Medical Problems

Mother
Father
Brothers:




Sisters:




Family Medical History: _______________________________________

                               BIRTH HISTORY

Birth Weight: _____       Gestation:<38 wks _____      38-42 wks _____

Pregnancy complications: _______________________________________

Delivery: Vaginal _____     Cesarean _____ Complications _____________

                          DEVELOPMENTAL HISTORY

Lifted Head     ______months               Drank from cup       ______months
Rolled Over     ______months               Toilet Trained      _______months
Sat Alone       ______months               Remembered Name       _____months
Stood Alone     ______months               Dressed self      ______months
Walked Alone    ______months               Displayed Independence _____ months

								
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