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Welcome to Pediatrix Patients are the focus of our attention. Call Pediatrix today at
(602) 866-0550. Contact Us

Pediatric New Patient Record

General Information

Dear Parents: Welcome to Pediatrix. Please complete this form, as it is a requirement for all patients new to our practice.






Do you vaccinate your child?



Section A: Patient History

1. Pregnancy, labor, birth and first week of life

A. Did you experience any unusual illness or complications during pregnancy?



B. Where was your child born?




C. Was your child born pre-term?



D. What was your child's birth weight?


E. Did your child have any unexpected hospitalizations during the first week of life?



2. Illnesses, Allergies and Development

Does your child suffer from any chronic condisions?



Does your child have any special needs?



Has your child ever been hospitalized?



Has your child ever had any surgeries?



Does your child have any allergies other than drug allergies?



As far as you know is your child's development normal?



Section B: Family History
1. Is this child's mother living?



In good health?


2. Is this child's father living?



In good health?




4. Are this child's siblings in good health?



5. Is there a family history of any type of illness or disease?



6. Are there significant family or marital problems?


7. Are there significant problems in income, housing, or sleeping arrangements?





10. Do the adults in the family usually agree on the rearing of this child?



Please bring your child's immunization record to the office visit.