General Health Questionnaire
Patient’s Name
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First Name
Last Name
What is your child’s DOB?
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Month
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Day
Year
Date
Is there anything about their health history we should know about?
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is there any Venezuelan Descent on Mother’s side of the family?
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What is your child's weight?
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Is your child Healthy?
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Have they ever been in the Hospital overnight? If so, how long and what for?
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Has anyone in else in your family ever had General Anesthesia? Who was it? Was it okay for them?
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Have they ever had General Anesthesia before? If so, what for and was it okay for them?
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Is your child taking any medications? If so, what is the medication and why are they taking it?
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Do they have any known drug, food, or seasonal allergies? If so, what are they and the reactions?
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Do they have an irregular heartbeat or murmurs?
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Do they have Asthma, Bronchitis, or a cold? If they have Asthma, does normal running and playing cause an attack?
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Do they have Diabetes, Thyroid, Stomach, Liver, Kidney or bleeding problems?
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Do they have Bone or joint problems?
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Does your child have any Developmental Delays (Autism, ADHD, Speech delay, etc.)? If so, what are they?
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Submit
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