began , issues now covering Physical times/wk, hrs/session, by whom , where , began , issues now covering Speech times/wk, hrs/session, by whom , where , began , issues now covering Toxin exposure history please circle (and explain) any possible exposures including dates: Chemical heavy metal poisoning lead old pipes old paint lead in toys from China mercury dental amalgams in child in mother during gestation fish consumption of mother during gestation, or fish consumption by child vaccinations before or during 2002 unfiltered water fungiside, insecticide, pesticide exposure Electrical poisoning hybrid car heavy duty lap top c. many electrical items in bedroom or long time of exposure Past medical history, Medical Problems: Date onset Date resolved treatment 1) Date onset Date resolved treatment Date onset Date resolved treatment 2) for what , when Hospitalizations: Surgeries: , when Medications: name of drug , dosage (mg) , # times/day name of drug , dosage (mg) , # times/day name of drug , dosage (mg) , # times/day Allergies to medications: , what happened to body Review of systems: Dermatologic: white, brown or red birthmarks
began , issues now covering Physical times/wk, hrs/session, by whom , where , began , issues now covering Speech times/wk, hrs/session, by whom , where , began , issues now covering Toxin exposure history please circle (and explain) any possible exposures including dates: Chemical heavy metal poisoning lead old pipes old paint lead in toys from China mercury dental amalgams in child in mother during gestation fish consumption of mother during gestation, or fish consumption by child vaccinations before or during 2002 unfiltered water fungiside, insecticide, pesticide exposure Electrical poisoning hybrid car heavy duty lap top c. many electrical items in bedroom or long time of exposure Past medical history, Medical Problems: 1) Date onset Date resolved treatment Date onset Date resolved treatment 2) Date onset Date resolved treatment Hospitalizations: for what , when Surgeries: , when Medications: name of drug , dosage (mg) , # times/day name of drug , dosage (mg) , # times/day name of drug , dosage (mg) , # times/day Allergies to medications: , what happened to body Review of systems: Dermatologic: white, brown or red birthmarks