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6440 W. Newberry Road, Suite 402, Gainesville, FL 32605 - Phone: (352) 333-5500 - Fax: (352) 333-5506
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New Patient Form

New Patient Formgnvpa2023-01-16T01:19:53-05:00
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Form Completed by
Sex
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(parent/guardian)

Child's Medical History

Has your child ever had ...

Allergies?
Please List
Asthma/Wheezing
Pneumonia
Chicken Pox
Frequent Ear Infections
Vision Problems
Hearing Problems
Skin Problems/Eczema/Hives
Seasonal Allergies
Seizures / Epilepsy
High Blood Pressure
Heart Defects / Disease
Liver Disease
Diabetes
Kidney Disease
Bladder Infections
Physical or Learning Disabilities
Bleeding Disorders/Hemophilia
Sexually Transmitted Infections
Emotional/Behavior Problems
Depression/Suicidal Thoughts
Hospitalizations/Surgeries
Physical/Sexual/Emotional Abuse
Bone or Joint Injuries
Dental Problems
Obesity/Overweight
Eating Disorders
Sleep Problems
Attention Deficit Disorder
Lead Poisoning
Vaccines Up-To-Date

Family Medical History

Has any parent(P), grandparent(GP), aunt(A), uncle(U), sister(S) or brother(B) had...

Severe Food Allergies
Asthma/Wheezing
TB/Lung Disease
Cystic Fibrosis
Genetic Disorders
Migraines
Heart Disease
Sudden Cardiac Death
High Blood Pressure
Stroke
High Cholesterol
Blood Disorders
Sickle Cell
Anemia
Thalassemia
Clotting Disorders
Diabetes
Seizures
Mental Illness
Depression
Suicide Attempts
Cancer
Breast Cancer
Cervical Cancer
Colorectal Cancer
Other type of Cancer
Birth Defects
Hearing Loss
Speech Problems
Kidney Disease
Alcohol/Drug Abuse
Hepatitis/Liver Disease
Irritable Bowel Syndrome
Thyroid Disease
Crohn Disease
Ulcerative Colitis
Attention Deficit Disorder
Mental Retardation
Family Violence
Has any family member ever had an unexplained, unexpected death before age 50?

Pregnancy and Birth History

Adopted
Prenatal Care
Illnesses during pregnancy:
Medications during pregnancy
Alcohol/Drug Abuse
Tobacco use
Problems at birth
Mom: Miscarriage
Baby
Please select all that apply
Type of Delivery
Newborn Hearing Screening
Did baby receive Hep B vaccine?

Psychosocial History

Is child in daycare
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Are parents divorced or separated
Tobacco use in household
Sleep Problems

Feeding & Digestion

Breast fed
Severe colic in first 3 months
Feeding problems
Good appetite
Vitamins or other supplement
Eats balanced diet
Constipation problems
Food allergies/issues

Medical History

Broken Bones
Serious accidents
Surgeries
Hospitalizations
ER visits / Urgent Care

CONTACT US

PHONE: (352) 333-5500
FAX: (352) 333-5506

6440 W. Newberry Road,
Suite 402
Gainesville, FL 32605

GPA@gnvpa.com

RESOURCES

  • Breastfeeding Support
  • Immunizations
  • COPE Program

EXTERNAL RESOURCES

  • Safety Proofing Information
  • Car Seat Recommendations
  • AAP.org
  • HealthyChildren.org
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We are excited to announce these providers are accepting new patients! Michael D. Wyatt, M.D., FAAP, Catherine G. Boon, M.D., FAAP, Mary C. Grooms, M.D., FAAP, Tanya E. Banks, APRN, Chris Schreier, APRN,DNP

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