#1

Child’s Name:

#2

Date:

#3

Age:

#4

Date of Birth:

#5

Sex:

#6

What do you hope to achieve for your child's visit with us?

#7

When was the last time the child felt well?

#8

Did something trigger the child's change in health?

#9

What makes the child better?

#10

What makes the child feel worse?

#11

How does the condition affect the child and the family?

#12

What do you think is happening and why?

#13

What do you feel needs to happen for your child to get better? If you have a magic wand what are three things you would like to change or erase?

#14

Present or Current Ilness/Symptoms/Diagnosis

#15

SYMPTOMS: (mark C for current and P for past symptoms) Is Abdominal pain a current (C) or past (P) symptom?

#16

SYMPTOMS: (mark C for current and P for past symptoms) Is Acid reflux a current (C) or past (P) symptom?

#17

SYMPTOMS: (mark C for current and P for past symptoms) Is Anemia a current (C) or past (P) symptom?

#18

SYMPTOMS: (mark C for current and P for past symptoms) Is Bad breath a current (C) or past (P) symptom?

#19

SYMPTOMS: (mark C for current and P for past symptoms) Is Bed wetting a current (C) or past (P) symptom?

#20

SYMPTOMS: (mark C for current and P for past symptoms) Are Bleeding gums a current (C) or past (P) symptom?

#21

SYMPTOMS: (mark C for current and P for past symptoms) Is Blood in urine a current (C) or past (P) symptom?

#22

SYMPTOMS: (mark C for current and P for past symptoms) Is Body odour a current (C) or past (P) symptom?

#23

SYMPTOMS: (mark C for current and P for past symptoms) Do they Bruise easily? (C) or (P) symptom?

#24

SYMPTOMS: (mark C for current and P for past symptoms) Are Canker sores a current (C) or past (P) symptom?

#25

SYMPTOMS: (mark C for current and P for past symptoms) Are Changes in appetite a current (C) or past (P) symptom?

#26

SYMPTOMS: (mark C for current and P for past symptoms) Is Congestion a current (C) or past (P) symptom?

#27

SYMPTOMS: (mark C for current and P for past symptoms) Is Constipation a current (C) or past (P) symptom?

#28

SYMPTOMS: (mark C for current and P for past symptoms) Is Cough a current (C) or past (P) symptom?

#29

SYMPTOMS: (mark C for current and P for past symptoms) Does the child Cry easily? (C) or (P) symptom?

#30

SYMPTOMS: (mark C for current and P for past symptoms) Is Diarrhea a current (C) or past (P) symptom?

#31

SYMPTOMS: (mark C for current and P for past symptoms) Are Dizzy spells a current (C) or past (P) symptom?

#32

SYMPTOMS: (mark C for current and P for past symptoms) Is Dry skin a current (C) or past (P) symptom?

#33

SYMPTOMS: (mark C for current and P for past symptoms) Is Eczema a current (C) or past (P) symptom?

#34

SYMPTOMS: (mark C for current and P for past symptoms) Is Excessive fatigue a current (C) or past (P) symptom?

#35

SYMPTOMS: (mark C for current and P for past symptoms) Is Excessive perspiration a current (C) or past (P) symptom?

#36

SYMPTOMS: (mark C for current and P for past symptoms) Are Flat feet a current (C) or past (P) symptom?

#37

SYMPTOMS: (mark C for current and P for past symptoms) Are Frequent headaches a current (C) or past (P) symptom?

#38

SYMPTOMS: (mark C for current and P for past symptoms) Is Gas a current (C) or past (P) symptom?

#39

SYMPTOMS: (mark C for current and P for past symptoms) Is Hearing loss a current (C) or past (P) symptom?

#40

SYMPTOMS: (mark C for current and P for past symptoms) Is Heart murmur a current (C) or past (P) symptom?

#41

SYMPTOMS: (mark C for current and P for past symptoms) Are High fevers a current (C) or past (P) symptom?

#42

SYMPTOMS: (mark C for current and P for past symptoms) Are Hives a current (C) or past (P) symptom?

#43

SYMPTOMS: (mark C for current and P for past symptoms) Is Hyperactivity a current (C) or past (P) symptom?

#44

SYMPTOMS: (mark C for current and P for past symptoms) Is Itchy anus a current (C) or past (P) symptom?

#45

SYMPTOMS: (mark C for current and P for past symptoms) Is Itchy nose (or picks nose) a current (C) or past (P) symptom?

#46

SYMPTOMS: (mark C for current and P for past symptoms) Is Itchy vagina a current (C) or past (P) symptom?

#47

SYMPTOMS: (mark C for current and P for past symptoms) Is Jaundice a current (C) or past (P) symptom?

#48

SYMPTOMS: (mark C for current and P for past symptoms) Are Joint pains a current (C) or past (P) symptom?

#49

SYMPTOMS: (mark C for current and P for past symptoms) Are Migraines a current (C) or past (P) symptom?

#50

SYMPTOMS: (mark C for current and P for past symptoms) Is Motion sickness a current (C) or past (P) symptom?

#51

SYMPTOMS: (mark C for current and P for past symptoms) Is Nervousness a current (C) or past (P) symptom?

#52

SYMPTOMS: (mark C for current and P for past symptoms) Are Nightmares a current (C) or past (P) symptom?

#53

SYMPTOMS: (mark C for current and P for past symptoms) Are Night sweats a current (C) or past (P) symptom?

#54

SYMPTOMS: (mark C for current and P for past symptoms) Is No appetite a current (C) or past (P) symptom?

#55

SYMPTOMS: (mark C for current and P for past symptoms) Are Nosebleeds a current (C) or past (P) symptom?

#56

SYMPTOMS: (mark C for current and P for past symptoms) Is Painful urination a current (C) or past (P) symptom?

#57

SYMPTOMS: (mark C for current and P for past symptoms) Are Parasites a current (C) or past (P) symptom?

#58

SYMPTOMS: (mark C for current and P for past symptoms) Is Psoriasis a current (C) or past (P) symptom?

#59

SYMPTOMS: (mark C for current and P for past symptoms) Is Rash a current (C) or past (P) symptom?

#60

SYMPTOMS: (mark C for current and P for past symptoms) Is Sensitivity to light a current (C) or past (P) symptom?

#61

SYMPTOMS: (mark C for current and P for past symptoms) Are Sleep problems a current (C) or past (P) symptom?

#62

SYMPTOMS: (mark C for current and P for past symptoms) Are Stomach aches a current (C) or past (P) symptom?

#63

SYMPTOMS: (mark C for current and P for past symptoms) Is Sore throat a current (C) or past (P) symptom?

#64

SYMPTOMS: (mark C for current and P for past symptoms) Are Teeth grinding a current (C) or past (P) symptom?

#65

SYMPTOMS: (mark C for current and P for past symptoms) Does the child Talk in sleep? (C) or (P) symptom?

#66

SYMPTOMS: (mark C for current and P for past symptoms) Does the child Walk in sleep? (C) or (P) symptom?

#67

SYMPTOMS: (mark C for current and P for past symptoms) Is Weight gain a current (C) or past (P) symptom?

#68

SYMPTOMS: (mark C for current and P for past symptoms) Is Weight loss a current (C) or past (P) symptom?

#69

SYMPTOMS: (mark C for current and P for past symptoms) Is Wheezing a current (C) or past (P) symptom?

#70

SYMPTOMS: (mark C for current and P for past symptoms) Are Vomiting spells a current (C) or past (P) symptom?

#71

MEDICAL HISTORY: (check all that apply)

#72

Medical History (Others)

#73

Sequence of Medical History

#74

Nutritional Supplements (please list). Include herbal and homeopathic as well.

#75

MEDICATIONS. (check all that apply, and indicate the length of time the child received each medication.)

#76

MEDICATIONS. Others (please list)

#77

Are you aware of any allergies to medications?

#78

IMMUNIZATIONS: (check all that apply)

#79

IMMUNIZATIONS: Other (specify)

#80

Were there any reactions to immunization(s) If so, at what age?

#81

MOTHER’S HEALTH DURING PREGNANCY: (check all that apply)

#82

MOTHER’S HEALTH DURING PREGNANCY: Other (specify):

#83

MEDICATIONS WHILE PREGNANT:

#84

MEDICATIONS WHILE NURSING (Mother):

#85

TERM:

#86

Weight at birth:

#87

Was pregnancy induced?

#88

Mode of Delivery

#89

Complications during labor?

#90

Medications during or after labor?

#91

Nutrition

#92

How long was the breastfeeding? Bottle feeding? or Mixed feeding given?

#93

When was formula started?

#94

When were solid foods first introduced?

#95

What were the first foods introduced?

#96

Did your baby have any of the following problems?