Gavini Pediatric Clinics 26850 Providence Pkwy, Ste 300, Novi,MI 48374*(248) 348-4200 Fax (248) 380-6457

www.yourkidsdoctor.com

Last Name First Name DOB Age Date

NEW PATIENT QUESTIONNAIRE

Instructions: Please fill out as completely as possible. All information will be kept confidential.

HEALTH CARE STATUS

Is your child under treatment for any illness/condition N      Y     If yes please explain:         Has your child had any allergic reactions to Food or bee stings? Please List: N Y Has your child had reactions to any immunizations? Please list: N Y Has your child had any hospitalizations other than Please list: N Y   Please list any medical problems:                               List the medications your child is taking now:   List Developmental & Behavior Problems:

FAMILY HISTORY

Please list any blood relatives who have had the following illnesses.   List any other problems Illness Relative Heart Disease   High Blood Pressure   Cancer   Diabetes   Blood Disease   Epilepsy   Asthma / Allergies   Tuberculosis   Other

Please list the general health, age and sex of parents, brothers and sisters.     Name General Health Age                                                   Have any of your children died? N Y If Yes, Please Explain:

*If you have a copy of the child's immunization please include it with this form.

Name of person completing the form: _________________________________

Relationship: ___________________________________ Date: ______________________ Signature: __________________________________