Fillable Pediatric New Client Form (Page 3 of 7) in pdf

Pediatric New Client Form Page 3

Download a blank fillable Pediatric New Client Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Pediatric New Client Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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RELEVANT MEDICAL HISTORY

Illnesses, Injuries, Surgeries, & Hospitalizations since birth: (Check all that apply)

 Meningitis

 Hernia repair

 VP shunt

 Head injury

 PDA repair

 Tracheostomy

 Bone fracture

 Circumcision

 Frequent ear infections

 Encephalitis

 G-tube insertion

 Failure to thrive

Other: ________________________________________________________________________________

Digestion: Frequency of bowel movements:  More than once daily  Once daily

 Once in 2 days

 Identified problem of chronic constipation

 Frequent diarrhea

Medications: ____________________________________________________________________________

Supplements: ___________________________________________________________________________

Allergies: _______________________________________________________________________________

 Regular Schedule

 Altered Schedule

 Other (Explain) _____________

Immunizations:

________________________________________________________________________________________

Medical Diagnoses with which your child has been labeled:

 Cerebral Palsy

 Seizure Disorder

 Hypotonia

 Autism Spectrum Disorder

 Developmental Delay

 Chromosomal Abnormality

 Other (Describe) ___________________________________________________________________

Pediatrician / Family Physician:

Name: _______________________________________________________

Address: ________________________________________________________________________________

Telephone: ___________________________

Fax: ___________________________

Neurological Evaluation:

Date & Results (including MRI’s): ______________________________________________________________

_____________________________________________________________________________________

Page 3 of 7

Pediatric New Client Form Page 3

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