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Pediatric Medical History

If not listed here: Please discuss with your physician

Social History

Child lives with (mark all that apply)(Required)
Number of siblings (brothers and sisters)(Required)
If applicable, how is the patient performing in school?(Required)
Any concerns about lead exposure?(Required)
Are there any guns in the home?(Required)
Are there working smoke detectors in the home?(Required)
Is there any violent behavior in the family?(Required)
Does anyone in the household smoke?(Required)
Childcare situation. Check all that apply.(Required)
Mark any concerns about your child(Required)

Birth History

If not listed here: Please Discuss with your Physician
Patient was born(Required)
Delivery was(Required)
Please indicate any maternal health problems during this pregnancy(Required)
Did baby have any problems after birth?(Required)
Is the child yours by(Required)

Nutrition and Feeding

If not listed here: Please discuss with your Physician
Feeding style(Required)
Milk intake now(Required)
Average ounces of milk per day (8 ounces = 1 cup)(Required)

Sleep

If not listed here: Please discuss with your Physician

Allergies

If not listed here: Please discuss with your Physician
Allergies(Required)

Medication

If not listed here: Please discuss with your Physician
Current medications
Please describe medications actively taken

Immunizations

Please bring your child's immunization records to his/her appointment
Has this child had immunizations?

Your Medical History

Please indicate if the PATIENT has a history of the following. Select all that apply. If none, select "No medical history."
Medical History(Required)
Surgical History(Required)
If not listed here: Please Discuss with your Physician

Family Medical History

Please indicate which of the PATIENT'S family members have had these illnesses:
Family Medical History(Required)
ADD / ADHD
Alcoholism
Anxiety
Asthma
Bipolar Disorder
Cancer
Depression
Diabetes (juvenille Onset)
Diabetes (adult Onset)
Coronary Artery Disease
High Blood Pressure
Migraines
Rheumatoid Arthritis
Rheumatoid Arthritis
Seizures / Convulsions
Sickle Cell Anemia

Contact Information

** Please provide your full legal name as it appears on your driver’s license and you Alberta Health Care number.
This field is for validation purposes and should be left unchanged.

Focused on patients

Call For An Appointment Today:
Hamptons: (780) 809-1955 Ext.1170th Street: (780) 440-8202