PEDIATRIC UROLOGY ASSOCIATES, P.C.

Patient Name: _____________________________    Date of Birth:___________

Why is your child being seen today? ____________________________________

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Is your child on any medication? Please list and include any regular medications
your child takes daily and dosage: ______________________________________

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Does your child have any chronic medical conditions (example:  spina bifida,
Down’s Syndrome, bleeding disorder, etc):   _____yes       ______no

If yes, explain: _____________________________________________________

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Does your child have allergies:  ___ yes        ____ no

If yes, please list: ___________________________________________________

Type of allergic reaction (please describe symptoms example:  hives, trouble
 breathing, etc):_____________________________________________________

List any surgeries your child has had and when the surgery was done:

Date (month/year)                                         Type of Surgery:

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List any hospitalizations (overnight stay in the hospital)

Date (month/year)                                         Reason for hospitalization:

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