Welcome to Our Office
(Pediatrics - 17 & under)
Date of Birth
Did a Physician refer you?
If referred by Physician, Physician name:
If referral is other than a Physician, please indicate:
If selected "Other" for referral, indicate here:
List any family members seen by Dr. Ulrich:
General Medical Information
Reason for today's appointment?
How long has this been a problem?
What prior treatment has your child received for this problem?
Are immunizations up to date?
Does child bruise easily?
Has child ever had cut such that bleeding was difficult to control?
Personal Medical History
Any Heart Problems
Other Medical History
High Blood Pressure
Kidney or Liver Disease
List any previous surgeries and the year the surgery was performed:
Do you have any objection to the use of blood products? (in the unlikely event they should become necessary)
Has your child or any family member had a reaction to any local or general anesthetic?
If "Yes", what type of reaction?
Does your child have any allergies to medication?
If medication allergies, please list them here:
Allergic to Latex?
Allergic to X-Ray Dye?
Does your child take any medications on a regular basis?
Please list all medications your child is currently taking as well as their respective doses:
Parent's Signature (please sign with mouse):