Child’s Full Name: * | |
Child’s Birthday: | Year |
Child’s Sex | Female Male |
Child’s Address: City: Postal Code: |
Caregiver’s Name(s): * | |
Caregiver’s Address: If Different from above |
Phone Home:* | |
Emergency Phone: | |
Siblings-Names & Ages: | |
Family Doctor/Pediatrician Name and Address |
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What are your major concerns about your child’s health? |
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What are your other concerns about your child’s health? |
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Have any of the above conditions been diagnosed? | Yes No |
If so, by whom? |
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Medical History |
How would you describe your child’s general state of health?? | Good Fair Poor |
Which of the following illnesses has your child had? |
Rubella (German Measles) | Never Mild Average Severe |
Roscolla | Never Mild Average Severe |
Impetigo | Never Mild Average Severe |
Measles | Never Mild Average Severe |
Scarlet Fever | Never Mild Average Severe |
Mononucleosis | Never Mild Average Severe |
Chicken Pox | Never Mild Average Severe |
Impetigo | Never Mild Average Severe |
Ear Infections | Never Mild Average Severe |
Mumps | Never Mild Average Severe |
Whooping Cough | Never Mild Average Severe |
Please list any medications, including over-the-counter, vitamins, homeopathics, herbs, etc. taken in the past: |
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Please list any present medications, including over-the-counter, vitamins, homeopathics, herbs, etc. |
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Please list your child’s immunizations: Diphtheria/Pertussis/Tetanus, Tetanus Booster, Measles/Mumps/Rubella, Haemophilus Influenza B, Flu, Hepatitis, Polio, Other | Please list all that apply:
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What was the date of the Tetanus Booster Shot? |
Please indicate if any immunization caused adverse reactions: | |
How many times has your child had Antibiotics? | |
For what reason?: | |
Dental History or cavities: | |
List all locations of child’s scars. |
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Prenatal Health |
How was the health of the mother during pregnancy | Poor Fair Good Excellent Unknown |
Mother’s Age at Child Birth: | |
How was the mother’s diet during pregnancy? | Poor Fair Good Excellent Unknown |
Did the mother receive pre-natal medical care? | Yes No Unknown |
Did the mother experience any of the following during pregnancy: Bleeding, High Blood Pressure, Nausea, Vomiting, Diabetes, Thyroid, Physical or Emotional Trauma or Other Symptoms | Please list all that apply:
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Explain Other maternal symptoms? |
Did the mother use any of the following during pregnancy: Tobacco, Alcohol, recreational drugs, Prescription drugs, Over the Counter Medication, Supplements, Other | Please list all that apply:
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Please give details of use of any of the above: |
BIRTH HISTORY |
Term Length | Full Premature Late |
If premature or Late, by how many weeks? |
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Length of labour |
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Baby’s Weight at Birth |
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Any complications? |
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Was the birth: Vaginal, C-Section, Induced, Forceps, Anesthesia Used | Please list all that apply:
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Did the baby experience any of the following symptoms after the birth? Jaundice, Rashes, Seizures, Birth Injuries, Birth Defects, Other | Please list all that apply:
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If “Other” please explain: |
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DIET |
How was your baby fed? Breast, Milk Based Formula, Soy Based Formula, Other | Please list all that apply:
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If “Other” please explain: |
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If you breast fed, how long did you continue? |
What foods were introduced before 6 months? Please list approximate months as well. |
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Foods 6 – 12 Months. |
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Did your child ever experience colic? | Yes No |
How Severe Was the Colic? | Mild Moderate Severe |
Does your child have any food allergies or intolerances? Please List |
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Do either of the parents have a chronic illness? | Yes No |
Please describe parent’s chronic illness |
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Does your child have any dietary restrictions (religious, vegetarian/vegan?) |
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TYPICAL DAILY FOOD INTAKE |
Breakfast. |
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Lunch. |
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Dinner. |
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Snacks. |
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Beverages-Total-Quantity. |
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Anything You Would Like to Add |
Comment | |
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