MM slash DD slash YYYY
Family Care Clinic location you are registering for:

Patient Information

Child's Name

First
Middle
Last
MM slash DD slash YYYY
Gender
Request for Records Transfer Complete?

Birth History

Was the birth:
Did mother have any illnesses/problems with her pregnancy?
Did the baby have any problems right after birth?
Before mother knew she was pregnant or at anytime during her pregnancy, did she:
Was the initial feeding:

Current and Past History

Is your child currently on any medication?
Does your child have any serious or chronic illnesses?
Has your child had any serious injuries or accidents?
Has your child had any surgeries?
Has your child ever been hospitalized?
Is your child allergic to any medications?
Has your child ever reacted to immunizations?
Does your child have or has your child ever had:

Household Information

Please list all those living in the child's home (Click plus sign to far right to add additional rows)
Name
Relationship to Child
DOB
 
Smokers in household?

Family Medical History (Parents, Siblings, Grandparents, Aunt and Uncles)

Have any family members had the following? (Check all that apply)