Child Health & Business Questionaire Form - Alberta

CHILD HEALTH & BUSINESS QUESTIONAIRE

(Confidential information necessary for your files and your health)

Today’s Date________________

Patient’s Name (first)__________________________(last)______________________ Birthdate________________ Age________

Address ________________________________________________________City__________________Postal Code____________

Mother’s Name (first)__________________________(last)________________Home # _____________Work #________________

Cell#___________________ E-Mail_____________________________

Address _______________________________________________________ City__________________ Postal Code_____________

(if different from Patient)

Father’s Name (first) _________________________(last)_________________Home# ______________Work#________________

Cell#________________ E-Mail____________________________

Address _______________________________________________________ City __________________ Postal Code_____________

(if different from Patient)

Financial Responsible Party or Parties___________________________________________________________________________

Siblings’ Names and Ages ____________________________________

_________________________________________

Dentist _________________________________________________ Family Doctor________________________________________

Please check box

………………………………………………………

Is your child adopted? (

YES

For hereditary characteristics)

Has your child reached puberty?………………………………………………………………………

YES

Girls: menstruation started?…………………………………………………………………………...

YES

Boys: voice changed?…………………………………………………………………………………

YES

Have you noticed a rapid rate of growth in the past year?…………………………………………….

YES

Height _________

Is your child in good health?…………………………………………………………………………...

YES

How would you describe your child’s temperament? ______________________________________

Has your child previously been or are currently under the care of a health care professional for any

kind of specific condition or syndrome?...............................................................................................

YES

If Yes, explain: ___________________________________________________________

Has your child ever been hospitalized or had a serious illness or accident?…………………………..

YES

If Yes, explain:_____________________________________________________________

Please list any medications your child is currently taking.______________________________________________________

____________________________________________________________________________________________________

OVER

Child Health & Business Questionaire Form - Alberta - Canada