graphic: kids

Is Your Child Sick?TM

Emergencies

Medical Emergency:
Poison Control:

Office After Hours:
Call 911
(800) 222-1222

(808) 524-2575

Prenatal Visit / First Time Newborn (Up To 2 Months Old)









What is the sex of the baby?:



Are you or do you plan to breastfeed?:



Have you had any breast surgeries?:



Did you or do you plan to circumcise?:



















Marital status:





OBSTETRIC HISTORY:





MOTHER'S MEDICAL HISTORY:




FATHERS'S MEDICAL HISTORY:




FAMILY HISTORY:

Has anyone in the family ever had or been treated for the following? (Include the child's siblings, mother, father, grandparents, aunts and uncles.)

Allergies:


Food allergy/intolerance:


Anemia:


Wheezing, asthma, bronchitis:


Positive PPD/TB:


Eczema or skin problems:


High blood pressure:


Heart problems:


High Cholesterol:


Hepatitis or liver problems:


Bowel problems:


Diabetes:


Thyroid problems:


Kidney problems:


Depression / psychiatric:


Drug or alcohol problems:


Stroke:


Seizures:


Cancer:



If the baby is already born, please fill out the following: