AMP Peds info form Name*Sex*MaleFemaleDate of Birth* Age*Grade in SchoolAddress* Street Address City State / Province / Region ZIP / Postal Code Mother’s Name*Mother’s OccupationFather’s Name*Father’s OccupationParents are (circle)*MarriedSeparatedDivorcedLiving TogetherOtherDoes your child have a primary care physician?*YesNoUntitledName of Previous or Current Pediatrician*Chief reason for office visitHas child been seen by any other doctor(s) for this complaint?*YesNoHas child had any blood work done? If yes, please list what and whenPlease list any operations or hospitalizations and year they occurred Please list all medicines and supplements child is currently taking Any known Allergies to food, drugs, environment, animals and their reaction (e.g. peanuts causes hives)Previous medical historyYes indicates the child gets the problem regularly No indicates the child never had the problem Past indicates the child had the problem in the past but not recently. Please circle the correct one for your child. Ear Infections?*YesNoPastColds?*YesNoPastStrep throat?*YesNoPastHow many total? (Ear Infections)*How many total? (Colds)*How many total? (Strep throat)*How many times has the child taken antibioticsWhat other medicines has the child taken in the past? How often? Hearing tests Normal*YesNoNot TestedVision Tests Normal*YesNoNot TestedAny speech impediments*YesNoPastLearning impediments*YesNoDon't KnowVaccination HistoryYes - has had | No - has not | Some - did not finish all shotsMMRYesNoSomeHep BYesNoSomeChickenpoxYesNoSomeDPTYesNoSomeHibYesNoSomePolioYesNoSomeOther Any reactions to vaccinations? If so, please explainFamily HistoryAllergiesYesNoCancerYesNoCardiovascular diseaseYesNoDiabetes mellitusYesNoObesityYesNoTuberculosisYesNoMental IllnessYesNoMother’s Pregnancy historyMother’s age at conceptionDid she have other children already?YesNoMother’s Health During PregnancySmokingYesNoCoffeeYesNoRecreational drugsYesNoPreeclampsiaYesNoVaginal birthYesNoDiabetesYesNoNausea/VomitingYesNoEmotional StressYesNoTraumatic birthYesNoLength of LaborIf the birth was difficult, please explainChild’s Birth WeightHealth of baby at birthChild breastfedYesNoFor how longWhen put on formulaFormula usedWhen was child put on solid foodChild’s first foodsWhen did child develop teethWalkTalkHealth History of childJaundice as babyYesNoCradle capYesNoEczema or psoriasisYesNoDiarrheaYesNoConstipationYesNoFinicky eatingYesNoPoor teethYesNoChronic snifflesYesNoBad foot odorYesNoVery sweaty baby/childYesNoHyperactivityYesNoGrowing painsYesNoColicYesNoAnemiaYesNoAsthmaYesNoWartsYesNoNightmaresYesNoBed-wettingYesNoTantrumsYesNoDisobedientYesNoFears/PhobiaYesNoDiaper RashYesNoEarly PubertyYesNoStomach achesYesNoAny particular stressors child has witnessed or gone throughDietTypical Day’s DietBreakfast Snack Lunch Snack Supper Other / Child’s favorite foods Toxin ExposureHas the child ever lived near a refinery or other highly polluted area?Has the child ever lived in a house with lead paint?Has the child ever lived in a house that had new paint, cabinets, carpeting installed and did that seem to affect their health at all?Do you spray pesticides or herbicides around the house?Do you use any other chemicals around the house? If yes, please describeDoes the child seem particularly sensitive to perfumes or other vapors / odors?Additional Comments or things the doctor should know This iframe contains the logic required to handle Ajax powered Gravity Forms.