Pediatric Medical History Form - North Park Pediatrics 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your child’s name and date of birth at the top of the form. This information is crucial for identifying your child's medical history.
3. In the 'Person Completing Form' section, provide your relationship to the child and the date you are completing the form.
4. Fill out the medications section by listing any medications your child is currently taking, including dosage and frequency.
5. Indicate any medication allergies by checking 'Yes' or 'No' and specify any reactions if applicable.
6. Complete the immunization history section, confirming whether your child is up to date on vaccinations.
7. Provide detailed birth history, including any complications during pregnancy and delivery method.
8. Check off any personal medical history items that apply to your child from the provided list.
9. If applicable, note any hospitalizations or surgeries your child has had, including dates and reasons.
10. Complete family history by indicating relevant diagnoses among family members.
11. Finally, fill out social history details about who lives at home and caregiving arrangements.

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