Pediatric Questionnaire

Tree of Life Health Solutions Pediatric Health Questionnaire

Patient Name

GirlBoy

Date

Child's BirthDate

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?

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

NoYes, which foods?

During Childhood: How was diet?

Any dietary concerns?

NoYes, which foods?

NoYes, 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

NoYes, injury, age?

NoYes, age it was removed.

NoYes

List other serious illnesses/hospitalizations/or surgeries (description & date)

NoYes, which ones?

NoYes, please explain.

NoYes, explain.

Are there any concerns you would like to discuss with the doctor today?

Date

Signature

Printed Name of Above