Intake Form

Step 1 of 4 - How to Have a Successful Medical Visit

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  • Family Medical History

  • Please enter a value between 0 and 1000.
  • Past Medical History

    The Medical History of Your Child
  • IllnessDescription 
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  • ReasonDescription 
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  • SurgeryDescription 
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  • ImmunizationDetails 
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  • ImmunizationDetails 
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  • Family History of Diseases

    This includes any blood relatives, 3 generations, the child’s parents, grandparents, great-grandparents, aunts, uncles, etc. on the mother AND father’s side of the family. For example: are the child’s grandparents, great-grandparents alive? What did they die from? It doesn't matter if the illnesses was due to cigarettes or alcohol. These illnesses still should be included.
  • Heart attacks, strokes, bypasses, defects
  • Please list Relation and any availble details
    RelationDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
    Add a row
  • Please list Relative and any availble details
    RelativeDetails 
    Add a row
  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
    Add a row
  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
    Add a row
  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
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  • Please list Relative and any availble details
    RelativeDetails 
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  • Social History

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