Pediatric Medical History

If not listed here: Please discuss with your physician

Television / Computers / Electronics hours daily(Required)

If not listed here: Please Discuss with your Physician

If premature, weeks gestation(Required)

Birth weight pounds(Required)

Birth weight ounces(Required)

Birth length (inches)(Required)

If not listed here: Please discuss with your Physician

If not listed here: Please discuss with your Physician

Hours of sleep per night(Required)

If not listed here: Please discuss with your Physician

If not listed here: Please discuss with your Physician

Current medication description(Required)

Please describe medications actively taken

Please bring your child's immunization records to his/her appointment

Please indicate if the PATIENT has a history of the following. Select all that apply. If none, select "No medical history."

Please indicate which of the PATIENT'S family members have had these illnesses:

** Please provide your full legal name as it appears on your driver’s license and you Alberta Health Care number.

First name(Required)

Last name(Required)

Alberta Health Care #(Required)

Name

This field is for validation purposes and should be left unchanged.

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