18-21-Year Child's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Best Phone # to Contact(Required)At what office is your appointment scheduled?(Required) Cranberry/Seven Fields Pleasant Hills Squirrel Hill/Greenfield Do you have any questions, concerns, or problems you would like to discuss?(Required) Yes No Please describe(Required)Have you received a COVID-19 vaccine?(Required) Yes No Please provide the kind, and the dates, of the COVID vaccine.(Required)Which one?(Required) Pfizer Moderna Johnson & Johnson Have you visited with other health care providers since your last visit to our office?(Required) Yes No Any new medical problems for the Family Medical History?(Required) Yes No Please describe(Required)Have there been any other major changes in your family in the past 12 months?(Required)(Check all that apply.) Child Care Move Job Change Relationship Change Death in Family Other None Please describe(Required)Will you need any forms completed at the time of your visit?(Required) Yes No Please describe(Required)NutritionDo you eat 3-balanced meals/day, have regular calcium intake, infrequently consume sweetened beverages, and eat healthy snack options?(Required) Yes No Please describe any specific concerns regarding your diet:(Required)In the past 12 months, did you ever worry you would run out of food before you had money to buy more?(Required) Yes No In the past 12 months, did you ever run out of food before you had money to buy more?(Required) Yes No Daily ActivitiesPlease tell us your duration of sleep and any specific sleep concerns:(Required)Do you have any concerns about voiding / stooling habits?(Required) Yes No Please describe(Required)Do you have any concerns regarding home, school or work, or friends?(Required) Yes No Please describe(Required)Please tell us about school, your grades, and what your goal is for school:(Required)Do you participate in activities (sports, music, art, other)?(Required) Yes No Please describe(Required)Do you currently work?(Required) Yes No Please describe(Required)CAPTCHA
English
Arabic
Chinese (Simplified)
Dutch
French
German
Italian
Portuguese
Russian
Spanish