Infant Health History

In order to provide your child the best possible care, please complete this form in detail. (Fields marked with a red * are required and your form will not be submitted if these are left blank.) Once submitted, you will see "Thank you" on the next page.

Name*

First Last

Date of Birth*

Gender*

Male
Female

Father's Name*

Mother's Name*

Address - if parent is already a practice member, please skip

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent's Cell Phone Number

Parent's Email Address

Primary Care Physician

Insurance Company

Insurance ID Number

Baby's birth weight*

Baby's length*

Type of birth

Were forceps or vacuum used?

Complications during delivery? Was baby pre-mature or late?

Were medications used during labor and delivery? (Pitocin, Epidural, etc.)

Did baby receive any medications?

Did baby have jaundice?

Yes
No

Was light therapy used?

Yes
No

If male, was baby circumcised?

Yes
No

Any complications?

Has baby received any vaccinations?

Yes
No

Do you plan on doing full vaccine schedule?

Yes
No

How is nursing going?

Are you supplementing with formula?

How often is baby feeding?

How well is your baby sleeping?

Please list any medications and what they are for:

Please list all surgeries/accidents:

What is primary health concern? If he/she is here for wellness care, please say "wellness".*

What diagnostic tests and/or treatments have been received?

Please check any of the following that your baby has experienced:

Family Health History

Please select which family members have or have had the following conditions:

Mother

Father

Grandparents

Siblings

Is there anything else you would like the doctors to know about?

Thank you for taking the time to fill out the health history, we look forward to seeing you soon.

Please make sure this submits properly. Areas with a red * must be completed, or it will not submit. Please correct and submit. Once submitted, you will see "Thank you" on the next screen.