Scribd
Upload
17 views

Health History

This questionnaire contains confidential medical information for Baby K, who is seeing Dr. Jon Jantz for a medical issue. Baby K was born with immature lungs and experienced breathing problems but was hospitalized for 4 days until the lungs matured and functioned normally. The document lists vaccinations and dates administered.

Uploaded by

kimberly_kroupa7832
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
17 views

Health History

This questionnaire contains confidential medical information for Baby K, who is seeing Dr. Jon Jantz for a medical issue. Baby K was born with immature lungs and experienced breathing problems but was hospitalized for 4 days until the lungs matured and functioned normally. The document lists vaccinations and dates administered.

Uploaded by

kimberly_kroupa7832
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 1

c c 

 
All questions contained in this questionnaire are strictly confidential
and will become part of your medical record.

 

 (Last, First, M.I.): Baby K X M F


0 0
   ! " 
 Dr. Jon Jantz
00

 
c cc #

$   Measles Mumps Rubella Chickenpox Rheumatic Fever Polio X Non-Applicable

 %   cepatitis B IPV


  X @ Birth X @  Months
X @  Months @ 4 Months
@ Months
DTaP PVC
X @  Months X @  Months
@ 4 Months @ 4 Months
@ Months @ Months
cib Rota
X @  Months X @  Months
@ 4 Months @ 4 Months
@ Months @ Months
 !  &     
Born with immature lungs and experienced breathing problems within seconds of being born. ce was hospitalized in the special care nursery for 4
days before lungs were mature and functioning normal.

You might also like