Child Medical History Please complete the form below or click the button below for a printable .pdf Print and Complete The Form PERSONAL INFORMATION (CHILD) Note: Please bring a fairly recent picture of your child that we may keep plus a baby picture that we may look at and return Child Name: First Name Last Name Parent(s) Name(s): First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Work Phone (###) ### #### Cell Phone (###) ### #### Email address Child Age Birth Date MM DD YYYY Gender Assigned at Birth Choose One Male Female What is Your Current Gender Parent(s) Occupation Siblings Name First Name Last Name Gender Choose One Male Female Birth Date MM DD YYYY Name First Name Last Name Gender Choose One Male Female Birth Date MM DD YYYY Name First Name Last Name Gender Choose One Male Female Birth Date MM DD YYYY HEALTH INSURANCE INFORMATION *Please note. We do not accept any health insurance. You are responsible for submitting your own claims. Health Insurance ID/Group # OTHER Primary Care Physician First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Your local Pharmacy Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country GENERAL Referred by Diagnoses or explanation given to you about your child. Date of diagnoses MM DD YYYY Other problems to be addressed. Describe your child to me, including his/her history. Please be as detailed as possible. When did you first notice the problem with your child? What did you first notice? What was the onset of the problem for your child Sudden Gradual Was there any event or illness that you or others think brought on your child’s symptoms? Tell me your child’s story. CHILD’S MEDICAL HISTORY PRIMARY DOCTOR (S) Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country THERAPIST(S) Type Choose One Speech Occupational Physical Other Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Hours/Week Type Choose One Speech Occupational Physical Other Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Hours/Week Type Choose One Speech Occupational Physical Other Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Hours/Week OTHER CARE-GIVERS Specialist(s) Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Evaluation MM DD YYYY Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Evaluation MM DD YYYY Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Evaluation MM DD YYYY Naturopath(s)/Homeopath(s) Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Evaluation MM DD YYYY Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Evaluation MM DD YYYY Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Evaluation MM DD YYYY Nutritionist Name First Name Last Name Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Evaluation MM DD YYYY Major surgeries – Please describe and give dates. Surgery Date(s) MM DD YYYY Results Surgery Date(s) MM DD YYYY Results Surgery Date(s) MM DD YYYY Results Major injuries – Please describe and give dates (broken bones, motor accidents, falls) Injury Date MM DD YYYY Results Injury Date MM DD YYYY Results Injury Date MM DD YYYY Results Illnesses Please list appropriate dates and any complications Ear infections Date MM DD YYYY Complications Sinus infections Date MM DD YYYY Complications Bronchitis Date MM DD YYYY Complications Pneumonia Date MM DD YYYY Complications Thrush Date MM DD YYYY Complications Chicken Pox Date MM DD YYYY Complications Seizures Date MM DD YYYY Complications Mono Date MM DD YYYY Complications Other Please List Date MM DD YYYY Complications MEDICATIONS Please bring your child’s vaccine records to the appointment. Previous supplements. Current supplements Previous medications Current medications. Please bring previous lab work to your child’s appointment. PRENATAL HISTORY Maternal age at delivery Illnesses during pregnancy. Medication(s) during pregnancy. Other complications during pregnancy. Complications during labor and delivery. Mode of delivery Choose One C-Section Vaginal If C-Section, explain why. If vaginal delivery, did you have forceps/vacuum? Medication(s) during labor and delivery? Length of Pregnancy Full term Premature How many weeks? Complications after delivery? Medication(s) given to child during hospital stay? DIETARY/NUTRITIONAL HISTORY Breast-fed Choose One Yes No If yes, how long? Bottle-fed? Choose One Yes No Brand of formula Begun at what age? For how long? Foods Begun at what age? First foods? Whole milk? Choose One Yes No If yes, begun at what age? Known allergies to food? (Please list) Food CRAVINGS? (Please list) FOODS MY CHILD EATS Cookies Choose One Daily 3–5 Times/Week 1-3 Times/Week Never Used to Eat Candy Choose One Daily 3–5 Times/Week 1-3 Times/Week Never Used to Eat Sweet foods Choose One Daily 3–5 Times/Week 1-3 Times/Week Never Used to Eat Caffeine (soda, tea, etc.) Choose One Daily 3–5 Times/Week 1-3 Times/Week Never Used to Eat Milk – Specify Type Choose One Cow Rice Soy Whole 2% 1% Skim Choose One Daily 3–5 Times/Week 1-3 Times/Week Never Used to Eat Cheese Choose One Daily 3–5 Times/Week 1-3 Times/Week Never Used to Eat Ice Cream Choose One Daily 3–5 Times/Week 1-3 Times/Week Never Used to Eat Salty Foods Choose One Daily 3–5 Times/Week 1-3 Times/Week Never Used to Eat Meat Choose One Daily 3–5 Times/Week 1-3 Times/Week Never Used to Eat Pasta Choose One Daily 3–5 Times/Week 1-3 Times/Week Never Used to Eat Bread – Specify Type Choose One White Wheat Other Check the most appropriate description below of your child’s diet. Mostly baby foods Mostly carbohydrates (bread, pasta, etc.) Mostly dairy (milk, cheese, etc.) Mostly meat Mostly vegetarian (vegetables, fruits, grains, etc.) Other, Describe: Describe your child’s stool pattern (frequency, color, odor, consistency) FAMILY HISTORY List any allergies, major illnesses, genetic diseases or problems (such as digestive issues or mental health problems) for each family member of your child. **If any family members are deceased, please also list their age at death and cause. Mother Father Siblings Maternal Grandparents Paternal Grandparents Others SOCIAL HISTORY Who lives in the home with your child? Parents Choose One Married Divorced Separated Domestic partner Are any children in your family adopted? Pets in the house Caregivers besides parents. List the people most important in the life of your child. Recent changes, losses, births, deaths, divorce, remarriage or moves Recent travel. Child response to these changes. Is your child involved in any sports, music or other activities? Please describe. How does your child interact with other children? How does your child interact with other adults What makes your child happy? What makes your child sad? What makes your child angry? What makes your child stressed? How do you as a parent deal with these emotions in your child? ENVIRONMENTAL HISTORY Do you, your child, or any family members practice any relaxation/stress management techniques? LOCATION Choose One City Suburban Wooded Farm Other WATER Choose One City Well Type of HEAT Choose One Electric Gas Oil Other Do you live near Choose One Power lines Woods Industrial areas Water (ocean, swamp, etc.) Does your home have a lot of Choose One Dust Mold Down/Feather items (pillows, stuffed animals, etc.) Are there specific areas in your home that you suspect have issues? Please describe Describe the bedroom of your child (Check appropriate response) Bedding: Synthetic Down Feather Mattress cover Crib Junior Bed Adult Bed Flooring: Wall-to-Wall Carpet Area rug Wood Glued down Synthetic Pad Window Treatment: Shades Blinds Thin curtain Thick curtain Valence Other, Please describe Other items in room including furniture, toys, stuffed animals? Flooring in other rooms: Child’s bathroom? Living room? Family room? Is your child sensitive to or bothered by any of the following? Perfumes/Cosmetics Cleaning Products Mold Paint Pollens/Grasses Soaps Animals (dander) Detergents Dust Gasoline Other, Please describe Please list known allergies THERAPIES AND DIETS Please indicate therapies and diets you have used and/or are using. Gluten Free Now Past Results Choose One Very Good Good None Bad Very Bad Bad then Good Comments Casein Free Now Past Results Choose One Very Good Good None Bad Very Bad Bad then Good Comments Yeast Free Now Past Results Choose One Very Good Good None Bad Very Bad Bad then Good Comments High Protein/Low Carb Now Past Results Choose One Very Good Good None Bad Very Bad Bad then Good Comments Salicylate Free Now Past Results Choose One Very Good Good None Bad Very Bad Bad then Good Comments Low Phenolics Now Past Results Choose One Very Good Good None Bad Very Bad Bad then Good Comments IgG reactive food avoidance Now Past Results Choose One Very Good Good None Bad Very Bad Bad then Good Comments Specific Carbohydrate Diet Now Past Results Choose One Very Good Good None Bad Very Bad Bad then Good Comments Feingold Now Past Results Choose One Very Good Good None Bad Very Bad Bad then Good Comments Low oxalate Now Past Results Choose One Very Good Good None Bad Very Bad Bad then Good Comments Other Now Past Results Choose One Very Good Good None Bad Very Bad Bad then Good Comments SIGNS AND SYMPTOMS Please check any signs/symptoms your child may demonstrate and note duration and details if appropriate Stimming (repetitive actions or movements) Mild Moderate Severe Duration Unique Details Head banging Mild Moderate Severe Duration Unique Details Aggressiveness (biting, kicking, biting others) Mild Moderate Severe Duration Unique Details Mood swings Mild Moderate Severe Duration Unique Details Irritability/tantrums Mild Moderate Severe Duration Unique Details Fears/anxieties Mild Moderate Severe Duration Unique Details Hyperactivity Mild Moderate Severe Duration Unique Details Inability to concentrate/focus Mild Moderate Severe Duration Unique Details Impulsive Mild Moderate Severe Duration Unique Details Seizures Mild Moderate Severe Duration Unique Details Poor coordination Mild Moderate Severe Duration Unique Details Sensitive to crowds Mild Moderate Severe Duration Unique Details Recurrent/chronic fever Mild Moderate Severe Duration Unique Details Flushing Mild Moderate Severe Duration Unique Details Difficulty falling to sleep Mild Moderate Severe Duration Unique Details Night waking Mild Moderate Severe Duration Unique Details Nightmares Mild Moderate Severe Duration Unique Details Bed wetting/soiling Mild Moderate Severe Duration Unique Details Headache Mild Moderate Severe Duration Unique Details Dark circles/puffiness under eyes Mild Moderate Severe Duration Unique Details Congestion Mild Moderate Severe Duration Unique Details Dripping nose Mild Moderate Severe Duration Unique Details Earaches Mild Moderate Severe Duration Unique Details Sore throats Mild Moderate Severe Duration Unique Details Cough Mild Moderate Severe Duration Unique Details Wheezing Mild Moderate Severe Duration Unique Details Canker sores Mild Moderate Severe Duration Unique Details Diarrhea Mild Moderate Severe Duration Unique Details Constipation Mild Moderate Severe Duration Unique Details Bloating Mild Moderate Severe Duration Unique Details Passing gas Mild Moderate Severe Duration Unique Details Belching Mild Moderate Severe Duration Unique Details Food craving Mild Moderate Severe Duration Unique Details Mucous/blood in stool Mild Moderate Severe Duration Unique Details Eczema Mild Moderate Severe Duration Unique Details Hives Mild Moderate Severe Duration Unique Details Acne Mild Moderate Severe Duration Unique Details Seborrhea (cradle cap) Mild Moderate Severe Duration Unique Details Sensitivity to insect bites Mild Moderate Severe Duration Unique Details Cracking/peeling hands Mild Moderate Severe Duration Unique Details Cracking/peeling fees Mild Moderate Severe Duration Unique Details Reflux Mild Moderate Severe Duration Unique Details Persistent colic Mild Moderate Severe Duration Unique Details Describe any other symptoms you would like me to know about your child. List any other history, pertinent thoughts or questions that you want to address. Thank you!
