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Patients name:___Fin #: ___Date of Birth: ___
REHAB SERVICES950 West. Wooster Street Bowling Green, Ohio, 43402
4193548950 (phone) 4193548748 (fax)PEDIATRIC OUTPATIENT HISTORY FORM
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How to fill out pediatric out-patient history form
How to fill out pediatric out-patient history form
01
Provide accurate personal information of the child such as name, date of birth, and contact information
02
Specify the reason for the visit and any symptoms the child may be experiencing
03
List any medical conditions, allergies, or current medications that the child may have
04
Include details of the child's medical history, such as past illnesses, surgeries, or hospitalizations
05
Provide information about the child's family medical history, including any genetic conditions or diseases
06
Note any immunizations that the child has received and the dates of vaccination
07
Sign and date the form to verify the information provided
Who needs pediatric out-patient history form?
01
Parents or guardians bringing their child to a pediatric out-patient clinic or doctor's office
02
Healthcare providers who are treating children in an out-patient setting
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What is pediatric out-patient history form?
Pediatric out-patient history form is a medical document that records the medical history and treatment provided to a child during an out-patient visit.
Who is required to file pediatric out-patient history form?
Pediatric out-patient history form is typically filled out by the child's parent or guardian, or by the healthcare provider treating the child.
How to fill out pediatric out-patient history form?
To fill out a pediatric out-patient history form, one needs to provide information about the child's medical history, current symptoms, past treatments, and any medications currently being taken.
What is the purpose of pediatric out-patient history form?
The purpose of pediatric out-patient history form is to provide healthcare providers with essential information about the child's health status, which helps in making informed decisions regarding diagnosis and treatment.
What information must be reported on pediatric out-patient history form?
Information such as the child's personal details, medical history, current symptoms, previous treatments, family medical history, and any allergies must be reported on pediatric out-patient history form.
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