7-10-Year Child's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Best Phone # to Contact(Required)Parent/Caregiver's Name(Required) First Last 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 Has your child received a COVID vaccine?(Required) Yes No Please provide the kind, and the dates, of the COVID vaccine.(Required)Please describe(Required)Has your child visited with other health care providers since your last visit to our office?(Required) Yes No Please describe(Required)Are there 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)NutritionDoes your child 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 child's 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 child’s duration of sleep, and any specific sleep concerns:(Required)Do you have any concerns about your child’s voiding / stooling habits?(Required) Yes No Please describe(Required)Do you have any concerns about your child’s behavior at home, at school, or with friends?(Required) Yes No Please describe(Required)Tell us your child’s current grade level, his/her grades, and if he/she utilizes any supportive services at school:(Required)Does your child participate in activities (sports, music, art, other)?(Required) Yes No Please describe(Required)CAPTCHA
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