Patient Registration Form Fields marked with an * must be filled out. Please complete in full – Thank you Patient InformationChild's Name* First Middle Last Child's Date of Birth* Sex*MaleFemaleAddress* Street Address City State / Province / Region ZIP / Postal Code Parent #1 InformationParent # 1 Name* First Last Parent #1 Date of Birth* Parent #1 Occupation*Parent #1 Employer*Parent #1 Email Address* Parent #1 Cell #*Parent #2 InformationParent #2 Name First Last Parent #2 Date of Birth Parent #2 OccupationParent #2 EmployerParent #2 Email Address Parent #2 Cell #SiblingsName First Last Date of Birth SexMaleFemaleName First Last Date of Birth SexMaleFemaleName First Last Date of Birth SexMaleFemaleEmergency ContactEmergency Contact Name* First Last Emergency Contact Phone*Insurance InformationName of Insurance Company*Who is the Policy Holder?* First Last Policy Holder's Date of Birth* ID #*Group #*Medical HistoryPlace of BirthAllergies* Medications* Birth WeightBirth LengthProblems (E.G. Jaundice, Prematurity) Family HistoryThank you for taking the time to complete this information. Please notify your physician of any changes in your child’s health at each visit. Please notify our front office staff of any changes in your personal data so that we may keep our record currentDiabetes*YesNoCommentsSeizures*YesNoCommentsAllergies*YesNoCommentsTuberculosis*YesNoCommentsHeart Disease*YesNoCommentsHigh Blood Pressure*YesNoCommentsStroke*YesNoCommentsElevated Cholesterol*YesNoCommentsCancer*YesNoCommentsDevelopmental History (if applicable)At what ages did the following occur?Sat up without helpFed selfCrawledBladder controlWalkedBowel controlSpoke 1st wordsDressed selfPut word togetherWere there any periods when your child quit talking?Was child breast or bottle fed?Any problems?Did your child have problems with an exaggerated gag reflex?Does child have any motor or coordination difficulties (i.e. throwing/catching a ball, riding a bike, jumping)? Please list and describe: Health and Medical History (if applicable)Ear InfectionsYesNoCommentsTubes in EarsYesNoCommentsTonsillitisYesNoCommentsHigh FeversYesNoCommentsFrequent ColdsYesNoCommentsRespiratory InfectionsYesNoCommentsSeizures (when was last one?)YesNoCommentsPlease list and describe any other important injuries, illnesses and major operations and when they happened. Has your child been to a neurologist?YesNoCommentsWhat other therapies is your child receiving? Has vision been examined?YesNoDate and ResultsDoes child wear glasses?YesNoAt what age were they prescribed?Has hearing been tested?YesNoDate and ResultsDoes child wear hearing aid?YesNoAt what age was it prescribed?