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Dr. Juntgen
Services
New Patients
317-846-5893
317-846-5893
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Appointments
Medical history
*
indicates a required field
Child's Full Name *
(required)
Date of Birth *
(required)
Primary Physician Name/Number *
(required)
Current Medications *
(required)
Allergies (foods/dyes/medications/metals) *
(required)
Recent Surgeries or Hospitalizations *
(required)
Please indicate if your child has a history or diagnosis of the following conditions:
Complications during pregnancy or delivery (including but not limited to prematurity) *
(required)
Yes
No
If yes, please explain:
Developmental delay or failure to thrive *
(required)
Yes
No
If yes, please explain:
Sinusitis, sleep apnea, or snoring *
(required)
Yes
No
If yes, please explain:
Congenital heart defect/disease or heart murmur *
(required)
Yes
No
If yes, please explain:
Asthma, reactive airway disease, cystic fibrosis or breathing problems *
(required)
Yes
No
If yes, please explain:
Jaundice, hepatitis, or liver problems *
(required)
Yes
No
If yes, please explain:
Gastroesophageal reflux disease (GERD), stomach ulcers, or intestinal problems *
(required)
Yes
No
If yes, please explain:
Lactose intolerance, food allergies, dietary restrictions, or eating disorder *
(required)
Yes
No
If yes, please explain:
Bladder or kidney problems *
(required)
Yes
No
If yes, please explain:
Scoliosis, limited us arms/legs, muscle/joint/bone problems *
(required)
Yes
No
If yes, please explain:
Rash/hives, eczema, or skin conditions *
(required)
Yes
No
If yes, please explain:
Impaired hearing, vision, or speech *
(required)
Yes
No
If yes, please explain:
Cerebral palsy, brain injury, epilepsy or seizures *
(required)
Yes
No
If yes, please explain:
Intellectual disability or learning delays *
(required)
Yes
No
If yes, please explain:
Attention Deficit/Hyperactivity Disorder (ADD/ADHD) *
(required)
Yes
No
If yes, please explain:
Behavioral, emotional, communication, or psychiatric problems/treatment *
(required)
Yes
No
If yes, please explain:
Abuse history (physical, emotional, sexual, or psychological) *
(required)
Yes
No
If yes, please explain:
Diabetes, hyperglycemia or hypoglycemia *
(required)
Yes
No
If yes, please explain:
Anemia, sickle cell disease/trait, or blood disorder *
(required)
Yes
No
If yes, please explain:
Hemophilia, easy bruising, or excessive bleeding *
(required)
Yes
No
If yes, please explain:
Cancer, tumor, chemotherapy, or radiation history *
(required)
Yes
No
If yes, please explain:
Bone marrow or organ transplant *
(required)
Yes
No
If yes, please explain:
Mononucleosis, tuberculosis, scarlet fever *
(required)
Yes
No
If yes, please explain:
MRSA, sexually transmitted disease, HIV/AIDS *
(required)
Yes
No
If yes, please explain:
Any other medical condition or diagnosis not listed above? *
(required)
Yes
No
If yes, please explain: