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Child's Name:
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Who is filling out this form (name and relation)?
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Email:
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How did you hear about our clinic?
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Personal Information
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Date of Birth:
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Age:
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Gender:
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Height (inches):
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Weight (kilograms):
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Ethnicity:
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Religious practices:
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Contacts
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Name:
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Address:
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Phone:
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Home:
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Work
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Other:
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Relation to child:
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Emergency Contact
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Phone:
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Home:
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Work:
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Insurance
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Private Insurer:
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Policy/Group #:
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Member ID/Certificate#:
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Primary Plan Member Name and DOB:
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Other health care providers
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1. Name:
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Occupation:
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Phone:
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2. Name:
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Occupation:
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Phone:
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3. Name:
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Occupation:
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Phone:
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What are the child’s chief concerns
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1.
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2.
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3.
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4.
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Prenatal Health
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What was mother’s age at childbirth?
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Did mother receive prenatal health care?
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If yes, what type?
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Other:
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What was mother’s health like at conception?
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What was mother’s health like during pregnancy?
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During pregnancy did the mother experience any of the following:
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NauseaDiabetesVomitingThyroid problemsHigh blood pressurePhysical traumaBleedingEmotional traumaEclampsiaDepression Other:
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Did the mother use any of the following during pregnancy:
(list amount, frequency and length of time used)
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Tobacco:
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Alcohol:
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Recreational drugs:
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Prescription drugs:
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Fertility drugs:
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Supplements:
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Other:
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Was the mother exposed to any of the following during pregnancy?
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PetsPaintNew carpetingNatural gasCarbon MonoxideNew homeCleaning products
Other:
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Birth History
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Term length:
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Full Term
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Premature:
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#weeks:
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Late:
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#weeks:
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Length of labour:
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Any complications at birth? (I. e. breech, trauma)
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Type of birth:
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Were any of the following drugs used during labour?
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Demerol
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Nitrous oxide gas
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IV Epidural
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Spinal Epidural
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Anaesthetic
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Antibiotics
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Any complications for the child after birth?
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Low birth weight
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Jaundice
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Respiratory difficulties
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Low APGAR score
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Rashes
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Seizures
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Birth injuries
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Birth defects
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Other:
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Nutrition
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Was child breast fed?
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How long?
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Any problems with weaning?
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Was child formula fed?
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What kind?
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What foods were introduced
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Before 6 months:
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Any reactions:
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Between 6-12 months:
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Any reactions:
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When where the following foods introduced (approximate age):
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Milk
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Wheat
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Soy
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Citrus
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Sweets
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Who prepares the child’s food?
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Describe a typical day’s diet:
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Breakfast:
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Lunch:
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Dinner:
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Snacks:
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Fluids (quantity):
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Does the child have any of the following?
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Food intolerances:
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Food Cravings:
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Aversions to food:
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Review of Symptoms
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Indicate any of the following which currently apply or have applied in the past to the child:
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General
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feverchillsfatigueweaknessmalaise
Other:
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Skin
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dryness/moistnessrashesmole/birthmarksacne, boilslesionseczemahivesitchinghot/cold
Other:
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Head
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headachehead injurydizzinessrashesdrynessitchy
Other:
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Eyes
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impaired visionglasses/contactspaindischargerednessitchingtearing or dryness
Other:
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Ears
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impaired hearingearacheitchingdischarge
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ear infections (how many? )
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Other:
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Nose and Sinuses
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frequent colds (how many per year? )
nose bleedsstuffinessitchingdischargesinus problems
Other:
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Mouth and Throat
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frequent sore throatsore tongue/mouthgum problemshoarsenessteethingdroolinglesions, loss of taste
dental cavities (how many? )
Other:
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Neck
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lumpsswollen glandsgoitrepain or stiffness
Other:
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Respiratory
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coughspitting up bloodwheezingasthmabronchitispneumoniapleurisyemphysemapain on breathingdifficulty breathingshortness of breathTuberculosisTuberculin test
last chest x-ray (date):
Other:
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Cardiovascular
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murmursrheumatic feverchest paindifficult feedingsweatingpalpitationscyanosispast ECG
other heart tests:
Other:
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GI
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trouble swallowingchange in thirst or appetitefood allergydiarrhoeaconstipationnausea vomitingvomiting bloodbloatingblack tarry stoolbelchingpassing gasindigestionrectal bleedingjaundice (yellow skin)haemorrhoidsabdominal painhernias
number of bowel movements/day,
is this a change
color of stool
is this a change
Other:
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GU
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rashrednesspain on urinationdischargeincreased frequencyfrequency at nightfrequent infectionsinability to hold urineurgencyhesitancyblood in urine
Other:
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Musculoskeletal
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joint painjoint stiffnessjoint swellingarthritisweaknesssprains/strainsbroken bonesmuscle spasms or crampsbackache
Other:
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Peripheral Vascular
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leg paincold hands/feetleg crampsextremity numbnessswelling or ulcers
Other:
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Neurologic
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tremorirritabilityseizures/convulsionsfaintingparalysismuscle weaknessnumbness or tinglingloss of memoryinvoluntary movementloss of balancespeech problemsdifficulty concentrating
Other:
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Endocrine
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heat or cold intolerancethyroid troubleexcessive thirsthungerincrease in urinationsweatingdiabeteshypoglycaemiahormone therapy
Other:
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Blood/Lymphatic
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anaemiaeasy bleedingeasy bruisingpast transfusionsenlarged lymph nodes
Other:
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Emotional
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depressionmood swingsanxietynervousnesstensionfears and phobiasalcohol abusedrug abuseinsomniaemotional traumaphysical trauma
Other:
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Sleep
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trouble falling asleeptrouble staying asleeprecurrent dreams/nightmaressleepwalknight terrorsbed wetting
Other:
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Medical History
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How would you describe the child’s general health status:
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Please indicate if your child has had any of the following with approximate dates:
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Serious illness:
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Hospitalizations:
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Surgery:
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Injury:
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Has your child been vaccinated for any of the following (provide dates):
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DPT (diphtheria, pertussis, tetanus)
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Date:
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“Flu”
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Date:
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Polio
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Date:
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Hep B
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Date:
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MMR (measles, mumps, rubella)
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Date:
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Hep A
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Date:
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Haemophilus influenza B
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Date:
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Tetanus booster
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Date:
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Has your child had any adverse reactions to any vaccination?
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Has your child had any of the following (provide dates):
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Rubella
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Date:
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Measles
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Date:
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Impetigo
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Date:
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Roseola
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Date:
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Scarlet fever
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Date:
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Mononucleosis
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Date:
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Chicken pox
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Date:
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Whooping cough
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Date:
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Ear infections
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Date:
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Mumps
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Date:
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Strep throat
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Date:
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Please list all current medications:
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Please list all current supplements:
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Please list past prescription medications:
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How many times has your child used antibiotics?
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Please list any allergies
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Food:
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Drugs:
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Environmental:
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Do you use an Epi-pen?
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Do you have a medical alert bracelet?
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Did your child ever have colic?
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How severe?
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Family History
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Maternal grandmother
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Maternal grandfather
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Paternal grandmother
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Paternal grandfather
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Mother
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Father
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Sibling
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Sibling
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Other
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Other
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I don't know my medical history
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Environmental History
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Is this child in daycare?
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Is this child in homecare?
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Is this child in school? Grade:
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What types of physical activities does this child participate in?
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How often?
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What are the child’s extracurricular activities?
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How much time does the child spend watching television and/or playing on computers/video games? Hours per day/week?
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Does anyone in the child’s home smoke?
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Are there any animals in the child’s home?
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How is the child’s home heated/cooled?
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Are there any other substances that you believe your child is being exposed to on a regular basis?
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How is the child’s temperament?
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Does the child have mood swings?
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How often?
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How is the child’s performance at school?
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Has the child ever been diagnosed with a learning disability?
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Does the child have any fears or anxieties?
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How would you rate the stress level in your household on a scale of 1-10, 10 being the most stressful:
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Any other concerns or considerations you would like the Naturopath to know about:
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