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(503) 628-9082

Mon: 9am – 1pm, 3pm – 6pm
Tues & Thurs: 8am – 12pm, 2pm – 5pm
Wed: 12pm-6pm Fri: 8am-1pm
Sat & Sun By Appointment Only

Pediatric Intake Form

    Patient Information




    If this injury is related to an auto accident, please fill out the Auto Accident Questionnaire.



    Current Health














    Health History













    Growth & Development


    At what age did the child:
    Patient/Hospitialization/Surgical history (please list below all surgeries and hospitalizations, including the year)
    Family History Review

    Check those involving immediate family and add identification: M=Mother; F=Father; S=Siblings; G=Grandparents
















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