Patient Inforation

Please Fill out these forms to the best of your knowledge. All answers will be kept confidential.

Date:

 Male   Female 

Emergency contact not living at the same address:

Primary Insurance Subscriber Information

Address (if different from above):

Other Parent/Partner/Guardian Information

Address (if different from above):

Whom may we thank for referring you?

As Parent(s) of ,I authorize Dr. Daghlian, Dr. Sokolowski and associates to examine and treat my child as necessary. By signing this form I am accepting responsibility for full payment of services rendered, including services that may not be fully covered by my insurance plan.

Signature:

New Patient Health History Form

Have you had any of the following medical issues? Please check the appropriate boxes.

ArthritisYesNo
Allergies to Drugs/FoodsYesNo
Allergies to LatexYesNo
AnemiaYesNo
Anxiety DisorderYesNo
Blood TransfusionsYesNo
CancerYesNo
Convulsions or EpilepsyYesNo
Congenital Heart DefectYesNo
DepressionYesNo
DiabetesYesNo
Facial/Head InjuriesYesNo
Handicaps/DisabiliesYesNo
Heart Defect/Heart MurmurYesNo
Hemophilia/Abnormal BleedingYesNo
HepatitisYesNo
High Blood PressureYesNo
HIV/AIDSYesNo
Hospital StaysYesNo
Kidney/Liver ProblemsYesNo
Learning DisabilitiesYesNo
Liver DiseaseYesNo
Mitral Valve ProlapseYesNo
OsteoporosisYesNo
PneumoniaYesNo
PregnancyYesNo
Rheumatic/Scarlet FeverYesNo
ShuntsYesNo
SmokingYesNo
Snoring/Sleep ApneaYesNo
StrokeYesNo
Thyroid DisorderYesNo
TuberculosisYesNo
OtherYesNo

Please list all medications and dosages:

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