Patient Last Name			First Name			MI
DOB			Sex	Male Female
Birth History (Please list Birth Weight, any Pregnancy Complications or Birth Complications)
Birth Weight
Other Birth Info
Hospitalizations / Surgery (Please list any Hospitalization &/or Surgeries, include dates and reasons)
Hospitization &  Surgery Information
Ongoing Medical Illnesses (Please list any ongoing medical illnesses.  i.e. Asthma, Eczema, Heart Murmurs, etc.)
Ongoing Medical Information
Family History (Please list any history of medical conditions or genetic disorders for immediate family members, parents or siblings)
Family History
Social History (Please list siblings' names, ages and sex)
Family History
Additional Information
Religon
Are birth parents married to each other?   YES NO			Are there step parents who care for the patient?  YES NO
Pets at home?	YES NO		Types of Pets
Smokers at home?	YES NO
Other information we should know