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Pediatric Newborn Record

General Information

Dear parents: Welcome to our office. Please complete this form, as it will help up learn more about your child and give your child a better examination.



Was your child seen in the hospital by one of our physicians?



Section A: Current Information

Breast feeding?


Formula feeding?



Is your child taking vitamins?



Is your child taking supplemental iron?


Section B: Past History
Did you experience any unusual illness or complications during pregnancy?



Where was your baby born?





D. What was your child's birth weight?


Did your baby experience difficulties during the newborn period?



Section C: Family History
Is this child's mother living?



In good health?


Is this child's father living?



In good health?




Are your other children in good health?



Do any family members have a history of any of the following conditions:











Are there significant family or marital problems?


Are there significant problems in income, housing, or sleeping arrangements for your child?





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