Welcome
We look forward to taking incredible care of you and your family...
Patient Name:
*
First Name
Last Name
Mother's Name
First Name
Last Name
Father's Name
First Name
Last Name
Gaurdian's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Sex:
Male
Female
Other
Height
Feet ' Inches''
Weight
pounds (lbs)
May we send appointment reminders via text?
Yes
No
Emergency Contact:
Race:
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black
White
Hispanic
Other
Decline to answer
Ethnicity:
Hispanic
Non-Hispanic
Insurance: PRIMARY
Insurance: SECONDARY
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Pharmacy Name
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Phone
-
Area Code
Phone Number
Pediatric Medical Questionnaire
What do you hope to acheive in your visit with us?
*
Current Medication
Name
Dose
How many times per day
How long
Medication
Medication
Medication
Medication
Medication
Drug Allergies
Name
Type of reaction
Drug
Drug
Drug
Drug
If you had a MAGIC WAND and could help your child in three ways, what would they be?
*
Wishes
1
2
2
When was the last time you feel your child was well?
Did something trigger your child's change in health?
Is there anything that makes your child feel worse?
Is there anything that makes your child feel better?
Please list current and ongoing problems in order of priority (ie. PREVIOUS FORMAL DIAGNOSIS)
Problem
Mild
Moderate
Severe
Prior Treatment/Approach
Excellent
Good
Fair
Describe Problem:
Describe Problem:
Describe Problem:
Describe Problem:
Describe Problem:
Describe Problem:
Medical History
Diseases/Diagnosis/Conditions (check appropriate boxes)
Gastrointestinal
Currently Diagnosed
Prior Diagnosis
Comments
Irritable Bowel Syndrome
Inflammatory Bowel Syndrome
Chron's
Ulcerative Colitis
Gastritive or Peptic Ulcer Disease
GERD (reflux)
Celiac Disease
Other
Cardiovascular
Currently Diagnosed
Prior Diagnosis
Comments
Heart Disease
Elevated Cholesterol
Hypertension (high blood pressure)
Rheumatic Fever
Mitral Valve Prolapse
Other
Metabolic / Endocrine
Currently Diagnosed
Prior Diagnosis
Comments
Type 1 Diabetes
Type 2 Diabetes
Hypoglycemia
Metabolic Syndrome (Pre-Diabetes)
Hypothyroidism (low thyroid)
Hyperthyroidism (overactive thyroid)
Endocrine Problems
Polycystic Ovarian Syndrome (PCOS)
Weight Gain
Weight Loss
Frequent Weight Fluctuations
Bulimia
Anorexia
Binge Eating Disorder
Night Eating Syndrome
Eating Disorder (non-specific)
Other
Cancer
Currently Diagnosed
Prior Diagnosis
Comments
Please Comment
Genital and Urinary Systems
Currently Diagnosed
Prior Diagnosis
Comments
Kidney Stones
Urinary Tract Infection
Yeast Infections
Other
Musculoskeletal / Pain
Currently Diagnosed
Prior Diagnosis
Comments
Arthritis
Fibromyalgia
Chronic Pain
Other
Inflammation / Autoimmune
Currently Diagnosed
Prior Diagnosis
Comments
Chronic Fatigue Syndrome
Autoimmune Disease
Rheumatoid Arthritis
Lupus SLE
Immune Deficiency Disease
Severe Infectious Disease
Poor Immune Function (frequent infection)
Food Allergies
Environmental Allergies
Multiple Chemical Sensitivities
Latex Allergy
Other
Respiratory Diseases
Currently Diagnosed
Prior Diagnosis
Comments
Frequent Ear Infections
Frequent Upper Respiratory Infections
Asthma
Chronic Sinusitis
Bronchitis
Sleep Apnea
Other
Skin Diseases
Currently Diagnosed
Prior Diagnosis
Comments
Eczema
Psoriasis
Acne
Other
Neurologic / Mood
Currently Diagnosed
Prior Diagnosis
Comments
Depression
Anxiety
Bipolar Disorder
Schizophrenia
Headaches
Migraines
ADD / ADHD
Sensory Integrative Disorder
Autism
Mild Cognitive Impairment
ALS
Seizures
Arthritis
Other
Previous Evaluations
Yes
No
Date Completed
Comments
Full Physical Exam
Psychological Evaluations
Wechsler Preschool and Primary
Scale of Intelligence
Speech and Language Evaluations
Genetic Evaluation
Neurological Evaluations
Gastroenterology Evaluations
Celiac / Gluten Testing
Allergy Evaluations
Nutritional Evaluations
Auditory Evaluation
Vision Evaluation
Osteopathic
Acupuncture
Occupational Therapy
Sensory Integration Therapy
Language Classes
Sign Language
Homeopathic
Naturopathic
Craniosacral
Chiropractic
MRI
CT Scan
Upper Endoscopy
Upper GI Series
Ultrasound
Injuries
Yes
No
Date of Injury
Comments
Back
Neck
Head
Broken Bones
Other
Surgeries
Yes
No
Date of Surgery
Comments
Appendectomy
Circumcision
Hernia
Tonsils
Adenoids
Dental Surgery
Tubes in Ears
Other
Other
Other
Blood Type
A
B
AB
O
Rh+
Unknown
Boold Type
Hospitalizations
Date
Reason
1
2
3
4
5
Immunizations
Check if Received
Year
Comments
Covid Booster
Hepatitis B
Rotavirus (RV)
Diphtheria, tetanus and acellular pertussis (DTaP)
Haemophilus Influenzae type b (Hib)
Pneumococcal Conjugate (PCV13)
Inactivated Poliovirus (IPV)
Influenze (IIV; LAIV)
Measles, Mumps, Rubella (MMR)
Varicella (VAR)
Hepatitis A
Meningococcal
Tetanus, diphtheria, and acellular pertussis (Tdap)
Human Papillomavirus
Meningococcal B
Pneumococcal Polysaccharide (PPSV23)
Is your child up to date with immunizations?
Yes
No
Do you feel immunizations have had an impact on your child's life?
Yes
No
Has your child experienced any major life changes that may have impacted their health?
Yes
No
Has your child ever experienced any major losses?
Yes
No
Have you ever sought counseling for your child?
Yes
No
Is your child or family currently in therapy?
Yes
No
If yes above, please explain
Does your child have a favorite toy or object?
Yes
No
has your child ever been abused, a victim of crime or experienced a significant trauma?
Yes
No
Average number of hours your child sleeps at night
>12
10-12
8-10
<8
Hours
Does your child have trouble falling asleep?
Yes
No
Does your child feel rested upon awakening?
Yes
No
Does your child snore?
Yes
No
Roles / Relationships (list family memebers)
Name
Relationship
Age
Gender
1
Male
Female
Other
2
Male
Female
Other
3
Male
Female
Other
4
Male
Female
Other
5
Male
Female
Other
Who are the main people who care for your child
Name
Occupation
1
2
Resources for emotional support? (check all that apply)
Spouse
Family
Friends
Religious / Spiritual
Pets
Other
Resource
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Gynecologic History
If Applicable
Age at first period
Menses Frequency
Length
Pain?
Yes
No
Clotting?
Yes
No
Has your period ever skipped?
Yes
No
If yes above, how long?
Last Menstrual Period?
Use of hormonal contraception such as:
Yes
No
How Long?
Birth Control Pills
Patch
Nuva Ring
Do you use contraception?
Yes
No
Condom
Diaphragm
IUD
Partner Vasectom
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GI History
Has your child ever travelled to foreign countries?
Yes
No
If yes above, where?
Has your child ever gone wilderness camping?
Yes
No
If yes above, where?
Has your child ever had:
Gastroenteritis
Diarrhea
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Dental History
Check all that apply
Yes
No
Comments
Silver Mercury Fillings
Gold Fillings
Root Canals
Implants
Tooth Pain
Bleeding Gums
Gingivitis
Problems With Chewing
Floss Regularly?
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Patient Birth History
Mother's Past Pregnancies
Number
Pregnancies
Live Births
Miscarriages
Mother's Pregnancy (check all that apply)
Yes
No
Comments / Specifics
Difficulty getting pregnant (>6 months)
Infertility drugs used (please specify)
In vitro fertilization
Drink alcohol
Smoke tobacco
Take Progesterone
Take prenatal vitamins
Take antibiotics (specify if during labor)
Excessive vomiting, nausea (>3 weeks)
Have a viral infection
Have a yeast infection
Have birth problems
Group B step infection
Have c-section (specify why)
Use induction for labor
Have anesthesia (specify what was used)
Use oxygen during labor
Have Rhogam (specify how many shots)
Gestational Diabetes
High blood pressure (pre-eclampsia)
High blood pressure / toxemia
Have chemical exposure
Total weight gain during pregnancy
(lbs)
Total weight loss during pregnancy
(lbs)
Pregnancy duration
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40 (full term)
41
42
43
44
(weeks)
Needed newborn special care?
Yes
No
Appeared healthy?
Yes
No
Easily consoled during first month?
Yes
No
Antibiotics first month?
Yes
No
Experienced no complications first month of life?
Yes
No
Weight at birth
(lbs)
Apgar score at one minute (if known)
Apgar score at five minutes (if known)
Early Childhood illnesses
Number
Number of earaches in first 2 years
Number of other infections in first 2 years
Number of times antibiotics taken in first 2 years
Number of courses of prophylactic antibiotics in first 2 years
First antibiotic at _____ months
First illness at ______ months
If your child has developmental problems, at what age did they occur?
0-1 months
2-6 months
6-15 months
16-24 months
after 24 months
Please indicate the approximate age in months for the following milestones
Months
Never
Sitting
Crawl
Pulled to stand
Potty trained
Walked alone
Dry at night
First words
Spoke Cleclearly
Lost language
Lost eye contact
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Medications
Current Medications
Name
Dose
Frequency
Start Date (month/date)
Reason For Use
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Medication
Past Medications (last 10 years)
Name
Dose
Frequency
Start Date (month/date)
Reason For Use
Medication
Medication
Medication
Medication
Nutritional Supplements (Vitamins / Minerals / Herbs / Homeopathy)
Supplication and Brand
Dose
Frequency
Start Date (month/date)
Reason For Use
Supplements
Supplements
Supplements
Supplements
Supplements
Supplements
Supplements
Have medications or supplements ever caused unusual side effects or problems?
Yes
No
If yes above, please describe
Frequent antibiotics? (>3 times/year)
Yes
No
Long term antibiotics?
Yes
No
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Family History
Check all that apply
Mother
Father
Brother(s)
Sister(s)
Children
Maternal Grandmother
Maternal Grandfather
Cancers
Colon Cancer
Breast or Ovarian Cancer
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory Arthritis
Inflammatory Bowel Disease
Celiac Disease
Asthma
Eczema / Psoriasis
Food Allergies, Sensitivities or Intolerances
Environmental Sensitivities
Dementia
Parkinson's
ALS or other Motor Neuron Diseases
Genetic Disorders
Substance Abuse
Psychiatric Disorders
Schizophrenia
ADHD
Autism
Bipolar Disease
Check all that apply
Paternal Grandmother
Paternal Grandfather
Aunts
Uncles
Other
Cancers
Colon Cancer
Breast or Ovarian Cancer
Heart Disease
Hypertension
Obesity
Diabetes
Stroke
Inflammatory Arthritis
Inflammatory Bowel Disease
Celiac Disease
Asthma
Eczema / Psoriasis
Food Allergies, Sensitivities or Intolerances
Environmental Sensitivities
Dementia
Parkinson's
ALS or other Motor Neuron Diseases
Genetic Disorders
Substance Abuse
Psychiatric Disorders
Schizophrenia
ADHD
Autism
Bipolar Disease
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Nutrition History
Has your child ever had a nutrition consultation?
Yes
No
Have you made any changes in your cild's diet because of health problems?
Yes
No
If yes above, please explain
Check all applicable special diets or nutritional plans that your child follows
Following?
Comments
Dairy Free
Diabetic
Feingold
Gluten Restricted
Gluten / Casein Free
Ketogenic
Low Oxalate
Specific Carbohydrate
Vegan
Vegetarian
Weight Management
Wheat Free
Yeast Free
Food Allergy
If your child avoids any particular foods please list the types and reasons why?
If your child could only eat a few foods daily, what would they be?
Check all factors that apply to your child's current lifestyle and eating habitats
Applicable?
Comments
Fast eater
Erratic eating pattern
Eat too much
Dislike healthy food
Time constraints
Eat more than 50% of meals away from home
Sesory issues with food
Picky eater
Limited variety of foods
Prefers cold food
Prefers hot food
Every meal is a struggle
Most family meals together
Use food as a bribe or reward
Erratic mealtimes
Most meals eaten at the table
High juice intake
Low fruit / vegetable intake
High sugar / sweet intake
Was your child breastfed?
Yes
No
Type of formula
Soy
Cow's Milk
Low Allergy
Other
Introduction of cow's milk at _____ months
Introduction of solid foods at ____ months
Mother's known food allergies or sensitivities
Any other eating concerns regarding your child?
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Activity
List type and amount of daily activites
Name
Amount Daily
Activity
Activity
Activity
Activity
Activity
How much time does your child spend watching TV?
How much time does your child spend on the computer or playing video games?
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Environmental History
Exposure History (please check all that apply)
Past
Current
Mold in bathroom
Damp cellar
Pest extermination (inside)
Pest extermination (outside)
Forced hot air heat
Had water in basement
Mold visible on exterior of house
Heavily wooded or damp surroundings
Mold in cellar, crawl space, or basement
Moldy, musty school / daycare
Tobacco smoke
Well water
Carpet in basement
Carpet in most parts of the house
Feather or down basement
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Some Things About Your Parents
Custody arrangements (if applicable):
Mother (personal)
Information
Age at childs birth
Ethnicity
Education
Father (personal)
Information
Age at childs birth
Ethnicity
Education
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