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8678 19th St, Suite #130 Rancho Cucamonga, CA 91701Tel: (909) 4835433 Fax: (909) 4836633 www.ranchocucamongachiropractor.comPediatric/Adolescent Health History Date Name Nickname Birthday / / Age
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How to fill out pediatricadolescent health history
How to fill out pediatricadolescent health history
01
To fill out the pediatricadolescent health history form, follow these steps:
02
Start by providing the name of the pediatric or adolescent patient.
03
Fill out the basic demographic information such as date of birth, age, and gender.
04
Specify the contact information of the patient, including address, phone number, and email (if applicable).
05
Document the medical history of the patient, including any previous illnesses, surgeries, or hospitalizations.
06
List any current medications or supplements being taken by the patient.
07
Detail any known allergies or adverse reactions to medications.
08
Provide information about the family medical history, such as any hereditary conditions or illnesses.
09
Describe the patient's immunization history and ensure all vaccinations are up to date.
10
Record any ongoing or chronic health conditions, including mental health issues.
11
Mention any recent diagnostic tests or screenings undergone by the patient.
12
Lastly, review the completed form for accuracy and make any necessary corrections before submitting it.
Who needs pediatricadolescent health history?
01
Pediatricadolescent health history is needed for healthcare providers who are involved in the care of children and adolescents.
02
This includes pediatricians, family physicians, pediatric nurses, and other medical professionals who provide healthcare services to pediatric and adolescent patients.
03
Parents or legal guardians of pediatric and adolescent patients may also need to fill out the health history form.
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