Family Health Assessment - Main Peds

  • Family Health Assessment

  • Patient's DOB*
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  • Today's Date*
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  • There are many factors that can impact your child's overall health. Please answer these questions regarding your family and household to the best of your ability. Thank you for taking an active role in your child's health care.

  • Who does your child live with? (check all that apply)*

  • Does your child have any other regular caregivers?*
  • Since your child's last well visit, have there been any changes in your family or household, such as (check all that apply)

  • Are there any new stressors in your family or household?*
  • Are there any new medical problems in your family?*
  • Does anyone in your family or household have a history of mental illness?*
  • Does anyone in your family or household smoke?*
  • Do you have any concerns about drug and/or alcohol problems in your family or household?*
  • Do you have any concerns about your safety or your child's safety in your household?*
  • Are there any obstacles in your family or household to maintaining a healthy lifestyle?*
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  • Should be Empty: