Known allergies: Regular medications: History of seizures/convulsions: What does your child eat: Age of onset: Frequency: How does your child eat: Concerns: When does your child sleep at night: Other Information: How long: When does your child nap: How long: Frequency: Concerns: Vision formally checked? Hearing formally checked? Results: Results: Date of last exam: Date of last exam: Concerns: Concerns: History of ear infections? Ear tube placement? Age: Date:
Known allergies: Regular medications: History of seizures/convulsions: Age of onset: Frequency: What does your child eat: How does your child eat: Concerns: When does your child sleep at night: How long: When does your child nap: How long: Frequency: Concerns: Other Information: Vision formally checked? Results: Date of last exam: Concerns: Hearing formally checked? Results: Date of last exam: Concerns: History of ear infections? Age: Ear tube placement? Date:
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