Children's Health History

This form is also available for download.

Personal Information

Authorized Individuals

The patient must be accompanied by one of the above persons to receive examination and/or treatment. If accompanied by a person not listed above, a note authorizing examination and treatment must be brought to the visit and signed by the parent or legal guardian.

Referring Physician Information

Pediatrician Information

If your child sees several physicians within a group practice, WE MUST HAVE AN INDIVIDUAL PHYSICIAN'S NAME before we can submit your bill to your insurance company.

Medications & Allergies

Family History

Patient History

Recent Symptoms

Other Medical Conditions

Birth History (Pediatric Patients Only)