Today’s date–––––––––––––––––––
Child’s Name:––––––––––––––––––––––––––––––––– Date of Birth:–––––––––––––––––––––
SSN:–––––––––––––––––––––– Gender: ––––M––––F Weight:––––––– Height:––––––––––––
Eye color:–––––––––––– Hair color:–––––––––– Race:––––––––––
Mother’s Name––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Address:–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Home Phone––––––––––––––––––––––– Work/Other Phone:––––––––––––––––––––––––––
Mother’s occupation:–––––––––––––––––––––––––––––––––––––––––––––
Father’s Name:––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Address (if different):––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Work/Other Phone:––––––––––––––––––––––– Father’s occupation:–––––––––––––––––––––––
Child’s siblings (with genders –––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Child’s Medical History:
Name of child’s pediatrician:––––––––––––––––––––––––––––––––––––––––––
Pediatrician’s Address:–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Pediatrician’s Phone:–––––––––––––––––––––––––––––––
Immunizations/Vaccinations (give dates if known) :––––––––––––––Oral Polio ––––––––––––––TB
–––––––––––––––––––––––DPT/DT/dT ––––––––––––––––––––MMR ––––––––––––––––––––Hep B
–––––––––––––––––––––––Hem. Influenza B ––––––––––––––––Varicella (chicken pox)
–––––––––––––––––––––––Pneumovax ––––––––––––––––––––Flu –––––––––––––––––––––Other
Dr. Pamela K. Hannaman, M.S., N.D., C.P.C.
WA State Licensed, Board Certified Naturopathic Physician
Master of Science Biochemistry • Certified Professional (Medical) Coder
13074 Fairway Lane, Ashland, VA 23005 • H.Office (804) 798-4133 • FAX (804) 752-4935 • Cell (804) 350-4152