Childs Past Medical History |
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| Has your child had any surgery? |
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| Has your child ever been hospitalized? |
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| Is your child allergic to any medications? |
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| Is your child allergic to any foods? |
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| Has your child been seen by a specialist? Who & When? |
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| Does your child have or has he/she ever had any of the following? |
| Frequent Ear Infection |
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| Problems with ears or hearing |
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| Asthma / wheezing |
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| Bronchitis |
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| Pneumonia |
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| Nasal allergies |
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| Any heart problem or heart murmur |
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| Anemia |
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| Bleeding Disorder |
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| Blood transfusion |
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| Frequent abdominal pain |
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| Constipation requiring doctors visits |
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| Bladder or kidney infection |
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| Bed-wetting (after 5 years of age) |
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| Any chronic or recurrent skin problems (Acne, exzema, etc) |
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Seizures |
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| Thyroid or other endocrine problems |
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| Diabetes |
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| Use of alcohol or drugs |
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| Celiac disease |
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| Concussion / Head Injury |
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| Any other significant problems |
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