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Has your child been evaluated or treated by anyone else related to these concerns? If yes, please list treatment history. <br /> MEDICAL HISTORY <br /> Who is your child's primary health care <br /> provider? <br /> Provider's address: <br /> Provider's Phone Number: j Provider's fax number: <br /> When was your child last seen? <br /> When was your child's last physical? <br /> What were the results of that physical? <br /> Child's height and weight: <br /> If child is female, has she begun menses? ❑Yes ❑ No Approximate age at onset: <br /> Has she experienced any interruption in i ❑ Yes ❑ No ❑I don't khow. <br /> menses? <br /> List any current prescriptions your child <br /> takes and the prescribing doctor. <br /> HEALTH AND SOCIAL HISTORY: <br /> Were there any complications related to pregnancy/delivery? —v <br /> Did your child have any health problems immediately after birth? <br /> Briefly describe your child's toddler years(easy to care for? Eating difficulties?,;etc.): <br /> Briefly describe your child's early school years(adjustment to school,friendships, etc.): <br /> Does your adolescent have any chronic health conditions? <br /> Has your child had any significant injuries or illnesses? <br /> Are there any significant stressors in your child's life right now or in the recent past(losses, moves,changes in family structure)? <br /> ............... .. <br /> Please list your child's strengths: <br /> Page 2 of 3 <br />