Pediatric Form

Pediatric Form
(to be completed by parent/guardian of children aged 0-12 years)
Date:
Name:

First NameLast Name
Mother's Name:

First NameLast Name
Mother's Occupation:
Phone (Work):

Area CodePhone Number
Father's Name:

First NameLast Name
Father's Occupation:
Phone (Work):

Area CodePhone Number
Phone (Home):

Area CodePhone Number
E-mail:
Child's Birth Date:

MonthDayYear
Child's Age:
Who referred you to this office?
Family Doctor:
Does this child see any other health care provider?

YesNo
If yes, details:
Please state your child’s primary reason for attending this clinic. Please list the first time you noticed the condition and describe any factors that you suspect may have a role in its onset and perpetuation:
Please list any other health concerns:
Please list past health problems and dates:
Past Medical History
Childhood Illnesses (please check and indicate child’s age at time of infection):

MeaslesRheumatic feverMononucleosisRubellaScarlett feverStrep throat (How many times? State below)MumpsPolioWhooping coughTonsillitisChicken poxEar infections (how many? State Below)PneumoniaFrequent coldsOther
Describe illnesses and dates:
Vaccinations Received
(please state date of vaccination, if recieved):
Diphtheria, Pertussis, Tetanus:

MonthDayYear
Polio:

MonthDayYear
Haemophilus influenza B:

MonthDayYear
Influenza:

MonthDayYear
Measles, Mumps, Rubella:

MonthDayYear
Chicken Pox:

MonthDayYear
Prevnar:

MonthDayYear
Other:

MonthDayYear
Any adverse reaction to their vaccinations (redness, crying, screaming, fever, limp?)
List all family members the child lives with:
Prenatal History
Parents health at conception (G=good, P=poor):
Was this child conceived naturally?

YesNo
Any fertility interventions?

YesNo
Any illness or difficulties during pregnancy? (Please Check)

NauseaDiabetesHypertensionThyroid problemsEmotional traumaVomitingBleedingIllnessPhysical traumaOther
List any drugs, alcohol, cigarette smoking or medications taken during pregnancy:
List any vitamins or other supplements taken during pregnancy:
Mother’s age at conception:
Father’s age at conception:
Mother’s pregnancy weight gain:
Birth History
How long was the pregnancy?

Full TermLatePremature
Number of weeks:
What was the labor?

SpontaneousInduced
Duration of labor:
Difficulties or complications:
What was delivery by:

C-sectionVaginal Birth
Where was the birth taken place?

HospitalHome Birth
What was the birth weight?
What was the birth length:
APGAR Scores:
After 1 minute:
After 5 minutes:
Interventions:

EpiduralEpisiotomyForcepsSuction
Complications:
Neonatal History
Any difficulties or complications soon after birth?

JaundicePoor feedingRespiratory DistressAnemiaConvulsionsInfectionsBirth DefectsColicRashesOther
Age began:
Sitting:
Crawling:
Walking:
Talking:
First Tooth:
Any problems with the child’s teeth ?
How would you characterize your child’s development?
Physical:

SlowAverageFast
Mental:

SlowAverageFast
Has child started puberty?

YesNo
If yes, when?
Nutrition
Infant feeding:
Breast fed – how long?
Formula fed – describe type:
When started:
Age of introduction of solids:
What were the first foods introduced?
Childhood eating habits:
Are there any food groups excluded from your child’s diet? Why?
General Questions
Has your child ever experienced any trauma?

FracturesAccidentsEmotional
Please describe:
Has your child ever been hospitalized?

YesNo
If so, please indicate why and the year:
Is your child taking any medication or supplements?

YesNo
If so, please list:
Please list medications your child has used in the past:
How many times has your child taken antibiotics?
Do you live close to any of the following?

IndustryPower linesHighwayDumpAirport
How would you describe your child’s daycare or school experience (if appropriate) in terms of performance, enjoyment and socialization?
Has your child had any specialized screening tests? Explain.
What are your child’s interests?
How many days/week does your child participate in out-of-school programs?
Would you characterize the home environment as:

Very StableStableStressfulVery Stressful
How many hours per day does your child use:
TV:
Computer:
Video Games:
Have you done any major renovations to your home recently?
How old is your home?
How long have you lived there?
Are there any pets in the household?
Is the child exposed to tobacco smoke?
Does your child have any drug allergies? Describe:
Does your child have any food allergies? Describe:
Has the child ever traveled outside Canada? Where and when?
Sleep
Sleep patterns during the first year:
Usual time child goes to bed and awakens:
Any napping during the day?
Difficulties in falling asleep or staying awake?
Sensitivities
Is your child particularly sensitive to any of the following?

ClaustrophobiaColdHeightDraftsHeatMusicSmellsSunlightWind
Briefly describe your child’s personality including both positive and negative characteristics:
GENERAL SYMPTOMS: (please indicate current symptoms or past):
Acne:
Eczema, rashes:
Hives, itching:
Changes in skin odor:
Changes in hair/nails:
Cradle cap:
Is there anything else you would like to add that you feel may be relevant to your child’s case?
Enter the message as it's shown*
Should be Empty:

Pediatric Form

Past Medical History

Vaccinations Received

Prenatal History

Birth History

Neonatal History

Nutrition

General Questions

Sleep

Sensitivities