Douglas R.

Coombs MD, FAAP

Please fill in all known information 520 East Medical Drive Suite 301
Bountiful, Utah 84010
Birth History: Birth Hospital: (810) 292-1464

Weight: Length: Birth date:

Name_________________________________________
Delivery Type (Circle all that apply):
Vaginal C-Section
ALLERGIES: _________________________________________
Full Term Premature_____wks
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Blood Type – Mother: Baby: Coombs:
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Feedings (circle): Breast Formula
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Hepatitis Shot (circle): Yes No
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Complications:
Date Problems Resolved
Childhood History: ____________________________________________________
Medications: ____________________________________________________
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Allergies to medications/foods/environment? ____________________________________________________
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Surgeries: ____________________________________________________
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Other Hospitalizations: ____________________________________________________
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Childhood Diseases (circle): ____________________________________________________
Chicken Pox Asthma RSV Croup ____________________________________________________
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Other: ____________________________________________________
Immunization (circle): Current Behind Not Sure ____________________________________________________
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Medical Problems: ____________________________________________________
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Family Medical History: ____________________________________________________
(Check if any family member has any of the following)
This Other ____________________________________________________
Child Parents Siblings Relative ____________________________________________________
Allergies/Hay Fever ___ ___ ___ ___ ____________________________________________________
Asthma/Wheezing ___ ___ ___ ___
Eczema ___ ___ ___ ___
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Frequent Headaches ___ ___ ___ ___ ____________________________________________________
Frequent Ear Infections ___ ___ ___ ___ ____________________________________________________
Eye Problems ___ ___ ___ ___ ____________________________________________________
Heart Murmur ___ ___ ___ ___
Heart Disease ___ ___ ___ ___
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High Cholesterol ___ ___ ___ ___ ____________________________________________________
High Blood Pressure ___ ___ ___ ___ ____________________________________________________
Urinary Tract Infections ___ ___ ___ ___ ____________________________________________________
Diabetes ___ ___ ___ ___
TB/Positive Skin Test ___ ___ ___ ___
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Hearing Problems ___ ___ ___ ___ ____________________________________________________
Birth Defects ___ ___ ___ ___ ____________________________________________________
Seizures/Convulsions ___ ___ ___ ___ ____________________________________________________
Learning Problems ___ ___ ___ ___
Mental Illness ___ ___ ___ ___
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Anemia ___ ___ ___ ___ ____________________________________________________
Bedwetting ___ ___ ___ ___ ____________________________________________________
Bleeding Disorder ___ ___ ___ ___ ____________________________________________________
Cancer ___ ___ ___ ___
Medication Reactions ___ ___ ___ ___
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