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How may we contact you?
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Here with parent?
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What brings you here today?
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For how long?
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How did it begin?
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Is this a new condition?
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What helps?
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What makes it worse?
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What treatments have you already tried?
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Status?
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Any other details?
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Allergies
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Current medications
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Current supplements
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Well-Child visit
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List any special health care needs your child has:
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Concerns about child’s development, learning, or behavior:
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Any concerns about your child's vision?
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Any concerns about your child's hearing?
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Recent major changes in household
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Other major changes in household
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Tobacco exposure
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Child care arrangements
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Infant
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Early Childhood
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Developmental milestones (2-5 days old)
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Developmental milestones (15 months old)
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Developmental milestones (1 month old)
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Developmental milestones (18 months old)
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Developmental milestones (2 months old)
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Developmental milestones (2 years old)
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Developmental milestones (4 months old)
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Developmental milestones (3 years old)
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Developmental milestones (6 months old)
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Developmental milestones (4 years old)
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Developmental milestones (9 months old)
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Developmental milestones (12 months old)
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Middle Childhood
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Developmental milestones (5/6 years old)
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Development (7/8 years old)
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Development (9/10 years old)
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Do you have pain?
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Frequency
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For how long?
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Out of 10, pain level is usually:
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Location of pain?
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Quality
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Pain increases with
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Pain decreases with
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Associated sxs
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Status?
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Do you have fatigue?
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Out of 10, if 10 is most fatigued:
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Digestive complaints
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Digestive symptoms
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Bowel movements per day?
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If not daily, BM per week?
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Sinus Congestion
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If so, describe mucus
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Runny Nose/Allergies
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If so, describe mucus
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Cough
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If so, describe mucus
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Additional symptoms
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Anything else we should know about?
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Is there anything else?
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GAD-7 Form: Over the last 2 week, how often have you been bothered by:
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Feeling nervous, anxious, or on edge
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Not being able to stop or control worrying
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Worrying too much about different things
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Trouble relaxing
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Being so restless that it's hard to sit still
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Becoming easily annoyed or irritable
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Feeling afraid as if something awful might happen
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How difficult is it to work, take care of the home, or get along with others?
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PHQ-9 Form: Over the last 2 weeks, how often have you been bothered by:
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Little interest/pleasure in doing things
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Feeling down, depressed or hopeless
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Trouble falling or staying asleep, or sleeping too much
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Feeling tired or having little energy
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Poor appetite or overeating
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Feeling bad about yourself, that you are a failure, have let yourself/your family down
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Trouble concentrating on things, such as reading the newspaper or watching TV
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Moving or speaking so slowly - or fidgety - that other people could have noticed
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Thoughts that you would be better off dead, or of hurting yourself
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How difficult is it for you to work, take care of things at home, or get along?
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