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PEDIATRIC INFORMATION FORM 13-17 YRS Patient Information Name Date Date of birth Age Parent/Guardian s name s Street address City State Zip code Email address Home phone Cell phone Insurance Provider/ID Whom may we thank for referring you Patient History How would you describe the pregnancy Normal Somewhat difficult Very difficult If you answered anything but normal why Above average Typical Behind schedule Any childhood illnesses/diseases Any surgeries Any accidents Has your child been...
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