Patient Information

By completing this form, I can gain a quicker understanding of you child and it will become a part of their confidential file. Please answer each question as completely as possible.

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* 1. Name of Child

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* 2. Date of Birth

DOB

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* 3. Age

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* 4. Sex

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* 5. Child lives with:

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* 6. Address

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* 7. School

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* 8. Grade

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* 9. Pediatrician/ Primary Care Physician:

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* 10. Current Medications

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* 11. Who is currently completing this form?

T