Skip to content
Creating Healthy Tomorrows...One Child at a Time
Main Menu
Home
Office Policies
Menu Toggle
Vaccines
No-Show Policy
Late Policy
After-Hours Answering Service Policy
Insurances Accepted
Prescription Refills and Immunization Cards
Referral Requests
School, Camp, and Sports Physicals
Authorization for Medical Care
Release of Medical Records
Meet Our Providers
Patient Portal
Patient and Parent Resources
Menu Toggle
Patient Forms
Parent Resources
Contact Us
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 6
Patient Name
*
First
Last
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Birth History
Maternal Age at Birth
*
Any Illnesses During Pregnancy?
*
Yes
No
Medication During Pregnancy?
*
Yes
No
Any of the Following During Pregnancy?
*
Smoking
Alcohol
Illegal Drugs
None
In Which Hospital Did You Deliver?
*
What Was Your Child's Gestational Age at Birth (e.g., Term = 40 weeks)?
*
Type of Delivery
*
Vaginal
Cesarean
Assisted Vaginal (e.g., with Forceps)
Next
Birth Weight
*
Length
Apgar Score
at 1 Minute and 5 Minutes
Respiratory Problems?
*
Nasal Cannula
CPAP
Intubation
Other
None
Jaundice?
*
Yes
No
Any Other Problems with Baby at Birth?
Pass Hearing Test?
*
Yes
No
Don't Know
Were You Ever Told Baby Was Breech in the Third Trimester?
*
Yes
No
Previous
Next
Developmental History
Indicate age in months when milestone attained
Smiled
Rolled Over
Sat Up
Walked
Spoke in Sentences
Potty-Trained
Current Grade Level
Previous
Next
Past Medical History
Hospital Admissions
Date and Reason
Surgeries
Date and Reason
Childhood Illnesses
Date and Illness
List of Medications
Prescription, Over-the-Counter, or Vitamins/Supplements
Allergies
Food, Drug, or Environmental
Previous
Next
Family History
e.g., Alcoholism, Blood Disorder, Epilepsy, Mental Illness, Tuberculosis, Asthma, Cancer, Heart Disease, Migraines, Sudden Death, High Blood Pressure, and Allergies
Father
Mother
Siblings
Paternal Grandmother
Paternal Grandfather
Maternal Grandmother
Maternal Grandfather
Previous
Next
Social History
Teenage Drugs/Alcohol Use?
*
Yes
No
Don't Know
Is Patient Adopted?
*
Yes
No
Teenage Smoking?
*
Yes
No
Don't Know
Does Patient Go to Daycare?
*
Yes
No
Do Any Family Members Smoke?
*
Yes
No
Teenage Sexual Activity?
*
Yes
No
Don't Know
Any Pets at Home?
*
Yes
No
Number Living in Household
*
Previous
Comment
Submit
9006 S Fry Rd, Ste D, Katy, TX 77494 | Tel: 281-665-3013 | Fax: 832-913-8163 | info@CincoWestPediatrics.com
Learn more
This is default text for notification bar
Learn more
