APPOINTMENTS:
972-548-7888

3701 Eldorado Parkway
McKinney, TX 75070
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Pediatric Healthcare Associates, PA Patient Registration & Health History
 

       
       
       
       
   
       
DOB:
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Required by Government  Mandate but you may refuse:    
   
       
   
       
   
       


   
(Parent/Legal Guardian)   (Parent/Legal Guardian)  
Birthdate:
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Birthdate:
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Initial History Questionnaire

Date Completed:
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Patient Birth Date:
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Sex:


Household

Name   Relationship To Child   Birth Date   Health Problems
 
 
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Are there siblings not listed? If so, please list their names and ages and where they live.
   
If mother and father are not living together or if child does not live with parents, what is the child’s current custody status?
   
If one or both parents are not living in the home, how often does he or she see the parent/parents not in the home?
   

Birth History

 
       
Was the baby born at term:

       
       
Was Initial feeding breast or bottle:

   

Did mother have any illness or problems with her pregnancy:

Did your baby have any problems right after birth:

During pregnancy did mother do any of the following:


Did your baby go home with mother from the hospital:


General

 
Do you consider your child to be in good health:

       
Does your child have any serious illness or medical condition:

       
Has your child had serious injuries or accidents:

       
Has your child had any surgery:

       
Has your child ever been hospitalized:

       
Is your child allergic to any medicines or drugs:

       
       

Development
 

Are you concerned about your child’s physical development:

Are you concerned about your child’s mental or emotional development:

Are you concerned about your child’s attention span:

If your child is in school:



Family Health History

Does your child have,or has he/she ever had:
 





















 
   

       
Date:
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