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HIPAA- Medical History Information
Office Location
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Please select your correct location for each form.
Lakeland
Brandon
Patient First Name
*
Patient Last Name
*
Email
*
Birthdate
*
Month
Day
Year
Primary Care Pediatrician Full Name
Phone Number
Address
Zip Code
Patient's Specialists (list all):
Are there any changes in your doctors?
Yes
No
If yes, please list:
Any changes or additions to diagnosis?
Yes
No
If yes, please list:
Please list your current medication(s) using the following format: Name/ Dose/ Frequency/ Purpose/ Method
Method choices might include: PO, IV, NG, Nebulizer, Aerosol.
List child's equipment:
School, Daycare or Preschool child attends:
Grade:
Other outside therapy?
PT
OT
ST
If yes, name of provider:
Frequency of each:
In school setting?
PT
OT
ST
Frequency:
PROVIDE MOST CURRENT EVALUATIONS FROM PROVIDER.
Does child require special diet/restrictions?
Yes
No
If yes, please list:
Areas of concern:
Safety issues:
Therapy goals?
The information above has been completed to the best of my knowledge and ability.
Full Name
Relationship to Patient:
*
Signature
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Date
*
Month
Day
Year
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