Alyx Health & Wellness
Alyx Howell, NTP, RN
Pediatric Medical History Form
Parent's Full Name
First Name
Last Name
Child's Full Name
First Name
Last Name
Child's age:
Child's Gender:
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Does your child have any chronic conditions or are they experiencing any acute or chronic symptoms?
Yes
No
Not Sure
If yes, please list them below as well as when they started and any additional details.
What are your concerns and goals in regards to your child's health?
Does your child have any allergies?
Yes
No
Not Sure
Please list them.
Is your child currently taking any medication?
Yes
No
Please list them.
Is your child currently taking any supplements?
Yes
No
If yes, please list them, including dose and how long they've been taking them.
What does your child's diet look like? Are there any foods or food groups that you avoid? What foods make up their diet (breakfast, lunch, dinner and snacks)? Be specific.
Please list out your child's pertinent medical history. Ie. past hospitalizations, history of antibiotic use, medical/lab testing, vaccine schedule (CDC schedule, delayed schedule, or exemptions), etc.
Any other pertinent information that you'd like to add?
Submit
Should be Empty: