Pediatric Questionnaire

Tree of Life Health Solutions Pediatric Health Questionnaire
Patient Name
Child's sex

Girl Boy
Date

Month Day Year
Date
Child's BirthDate

Month Day Year
Date
Birthplace: Hospital/City/State
Duration of pregnancy
Were there any illnesses or complications, and if so, during what month of pregnancy?
Birth weight
Length
Any difficulties at the time of delivery?
In the nursery and the first 4 weeks, were there: Breathing problems?
Breathing problems?
Convulsions?
Was there yellow jaundice requiring treatment?
Child lives with

Both parents; Mother only; Father; Other relative or guardian
Please markif yourchild's blood relatives have ever had any of the following conditions.
Anemia (Sickle Cell, Mediterranean, etc.)
Bleeding disorders (Hemophilia)
Thyroid disease (Goiter, Nodule)
Diabetes
High blood pressure
Rheumatic fever or Rheumatic heartHeart attack before age 55
Cystic Fibrosis
Allergies (Eczema, Hay fever, Hives)
Seizures (Epilepsy)
Alcoholism or drug abuse
Cancer or Leukemia
Sudden or unexplained death
SIDS
Other
Nutrition
During Infancy: Breast/bottle fed?
Breast/bottle fed?
Duration
Was the baby allergic or intolerant of any foods?Yes or

No Yes, which foods?
During Childhood: How was diet?
Any dietary concerns?
During Adolescence: History of skipping meals/purging/restricting behavior?

No Yes, which foods?
Development: Any history of developmental delay in your child?

No Yes, describe.
Growth: Any concerns about your child's growth or failure to thrive?

No Yes, describe.
Indicate the age(s) at which your child might have had any of the following:
Mumps
Chickenpox
Whooping Cough
Rheumatic Fever
Asthma
Anemia
Convulsions
Disease
Pneumonia
Hepatitis (Jaundice)
Regular (Red, Hard) Measles
Scarlet Fever
Heart
Kidney/Urinarydisease
Rubella/German/3 day measles
Constipation
Hearing loss
Vision Problems
Eczema
Has the child ever been seriously injured?

No Yes, injury, age?
Has the child had tonsils or adenoids removed?

No Yes, age it was removed.
Has the child ever had a blood transfusion?

No Yes
List other serious illnesses/hospitalizations/or surgeries (description & date)
Is your child regularly taking any medications/supplements?

No Yes, which ones?
Is your child allergic to any medicines/foods etc.

No Yes, which ones?
Are there behavior problems at home?

No Yes, please explain.
Is there any history of learning difficulties/disabilities or problems at school?

No Yes, explain.
Are there any concerns you would like to discuss with the doctor today?
Date

Month Day Year
Date
Signature

Clear
Printed Name of Above
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