1. Identifying information<br><br>

What is the child's gender?  <br>

___________________________<br><br>
What is her/his name?  <br>

___________________________<br><br>
Where and when was she/he born?  <br>

___________________________<br><br>
How old is she/he?   <br>

___________________________<br><br>
What is her/his father's name?   <br>

___________________________<br><br>
What is her/his mother's name?   <br>

___________________________<br><br>
Are they living?  <br>

___________________________<br><br>
Where are they now?   <br>

___________________________<br><br>
What is today's date?   <br>

___________________________<br><br>
What is the source of this history?  <br>

___________________________<br><br>
What are the sources to verify this history?   <br>

___________________________<br><br>
What is the reason for consultation?  <br>

___________________________<br><br>