Child Medical History
Please fill out this form for your child before their first appointment
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Does the patient currently have any problems in the following areas:
Does the patient currently have any problems in the following areas:
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Family History
Family History
Please note the relationship to patient of the person affected (Father, mother, brother, sister, etc.)
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Social History
Social History
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Siblings
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Drug Allergies
Drug Allergies
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Medications
Medications
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Eye Surgeries
Eye Surgeries
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.