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The Pediatric Clinic UPDATED Medical History Information Complete and accurate information allows us to provide better care for your child *Patient’s Name (use one form per child): ____________________________ *Date of Birth: _____________ *What is your preferred method for us to contact you? Phone, text, email? Let us know. *Contact Information: _____________________________________________________________________ ***BE SURE TO CONTACT US WITH CHANGES.*** *Preferred Pharmacy: ___________________________ and if more than one, location: __________________ THIS PATIENT’S PAST MEDICAL HISTORY *Any allergies to any medications? No Yes If yes, which medications and what was the reaction? _______________________________________________________________________________________ *Is this child taking any medications, breathing treatments, vitamins, supplements? No Yes If yes, list the medication(s) and how often used (daily or only as needed): _______________________ ______________________________________________________________________________________ *In the past year, has your child been diagnosed with any of the following?: o o o o o o o o o o NO NEW CONCERNS Adopted Anemia Asthma/Wheezing ADHD Behavior Problem Bleeding Disorder Cancer __________ o o o o o o o o Chicken Pox Dental Problems Diabetes Food Allergies Frequent Illnesses Growth Problem Heart Defect or Murmur HIV o o o o o o o o Infections Kidney Disease Learning Disability Prematurity Seasonal Allergies Seizures Stomach Problems Urinary Tract Infection OTHER: __________________________________________________________________________ SERIOUS INJURY / HOSPITALIZATIONS / ANY SURGERY (including ear tubes): ________________________________________________________________________________________________________ *Anything else we should know: _________________________________________________________________________________ SOCIAL HISTORY This child lives with (circle): mother father siblings stepsibling half-sibling foster parent grandmother grandfather aunt/uncle stepmother stepfather other: _____________________ FAMILY MEDICAL HISTORY In the past year, has there been any medical problems in your family history that we should know about? Include relationship to this child: __________________________________________________________________ _________________________________________________________________________________________ Person completing form: _____________________________________________________ SIGNATURE AND RELATIONSHIP ____________ TODAY’S DATE