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Richfield Family Medicine
Portraiture
Blog
Contact
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Name
*
Name
First Name
Last Name
Medical History (check all that applies to patient)
Chicken Pox
Depression
Hearing Loss
Drug Usage
Speech problems
Excessive Thirst
Seizures
Smoking
Asthma
Anemia
Alcohol use
Headaches
Learning Disabilities
Weight loss/gain
Diabetes
Nutrition History (check all that your child eats)
*
Milk
Cereal
Vegetables
Fruits
Pop
Juice
Meats
Junk Food
Good Eater
Picky Eater
What grade is the child in?
*
If attending College what year?
Are there problems in school?
*
Yes
No
If yes, what are the problems
Is the child often sad or depressed?
*
Yes
No
Do you have a penis discharge?
Yes
No
Do you have a sore on your penis?
Yes
No
Are you sexually active?
*
Yes
No
Do you use condoms?
Yes
No
Age of first period?
Painful Periods?
Yes
No
Do you use birth control
Yes
No
If yes, what do you use?
Family History
Father
Diabetes
Cancer
Heart Disease
High Blood Pressure
Thyroid Disease
Asthma
Anemia
Drug/Alcohol Problems
Mother
Diabetes
Cancer
Heart Disease
High Blood Pressure
Thyroid Disease
Asthma
Anemia
Drug/Alcohol Problems
Siblings
Diabetes
Cancer
Heart Disease
High Blood Pressure
Thyroid Disease
Asthma
Anemia
Drug/Alcohol Problems
Grand Parents
Diabetes
Cancer
Heart Disease
High Blood Pressure
Thyroid Disease
Asthma
Anemia
Drug/Alcohol Problems
Smoke Detector in home?
*
Yes
No
Does the child where seat belt in car?
*
Yes
No
Does the child where a helmet when riding bike?
*
Yes
No
Has the child had a dental check up?
*
Yes
No
Has the child had a vision exam?
*
Yes
No
Does the child have exposure to second hand smoke?
*
Yes
No
Is the child exposed to lead?
*
Yes
No
Is there any family abuse in your home?
*
Yes
No
Is there any firearms in your home?
*
Yes
No
Are they locked up?
Yes
No
Please list any allergies.
Please list Current Medications Name, dose, and how often taken
Please list all Hospitalizations reason and time frame.
Thank you!