Download Naturopath - Balanced Living

Pediatric Health History Form
Child’s name: ________________________________________ Date of birth: ______________________ Sex M F
Date: _____________ Referred by: _______________________________
Who is filling out this form? ______________________________________________
(name and relation)
Contacts (in order of preference)
Phone numbers
Name ______________________________________ Home ________________________________
Address ____________________________________ Work ________________________________
___________________________________________ Other ________________________________
___________________________________________ e-mail ________________________________
Relationship to child __________________________________________________________________
Name ______________________________________ Home ________________________________
Address ____________________________________ Work ________________________________
___________________________________________ Other ________________________________
___________________________________________ e-mail ________________________________
Relationship to child __________________________________________________________________
Name ______________________________________ Home ________________________________
Address ____________________________________ Work _________________________________
___________________________________________ Other _________________________________
___________________________________________ e-mail _________________________________
Relationship to child ___________________________________________________________________
May we leave messages relating to your visits? Yes No Which contact method? Email Home Work Other All
With whom does the child live? _____________________________________________________
What are your child’s health concerns, in order of importance?
1. _______________________________________________________________________
2. _______________________________________________________________________
3. _______________________________________________________________________
4. _______________________________________________________________________
5. _______________________________________________________________________
Other health care providers:
1.
_______________________________
_______________________________
_______________________________
_______________________________
(____)__________________________
2.
_______________________________
_______________________________
_______________________________
_______________________________
(____)__________________________
3.
_______________________________
_______________________________
_______________________________
_______________________________
(____)__________________________
1
Medical History
How would you describe your child’s general state of health? Excellent
Good
Fair
Poor
Please indicate any serious conditions, illnesses or injuries, and any hospitalizations, along with approximate dates:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Which of the following has your child had? (n- never, m- mild, a- average, s- severe)
Rubella (German measles) n m a s
Roseola
n m a s
Measles
n m a s
Scarlet fever
n m a s
Chicken pox
n m a s
Whooping cough n m a s
Mumps
n m a s
Strep throat
n m a s
Impetigo
n
Mononucleosis n
m
m
a
a
s
s
Does your child have any allergies (medicines, foods, environmental, etc.)?
________________________________________________________________________________________________
________________________________________________________________________________________________
Please list all current medications (prescription, over-the-counter, vitamins, herbs, homeopathics)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Please list past prescription medications.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
How many times has your child been treated with antibiotics? ______________________
Please indicate what immunizations your child has had:
□ DPT (diphtheria, pertussis, tetanus)
□ Haemophilus influenza B
□ Tetanus booster; when? _______________ □ “Flu”
□ MMR (measles, mumps, rubella)
□ Polio
Other ________________________________
□ Hepatitis B
□ Hepatitis A
□ Chicken pox
2
Please indicate if any caused adverse reactions:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
What screening tests has your child had (blood, hearing, vision, etc.)?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Please indicate areas of skin concerns (rashes, eczema, psoriasis, etc.) by shading in the body parts on the diagram
below:
Prenatal health
What was the health of the parents at conception?
Mother
Poor
Fair
Father
Poor
Fair
Good
Good
Excellent
Excellent
Unknown
Unknown
3
What was the health of the mother during the pregnancy?
Poor
Fair
Good
Excellent
Unknown
What was the mother’s age at child’s birth? ____________________
How was the mother’s diet during pregnancy?
Poor
Fair
Good
Excellent
Unknown
Did the mother receive prenatal medical care? Yes
No
Unknown
Did the mother experience any of the following during the pregnancy?
□ Bleeding
□ high blood pressure □ Nausea
□ Vomiting
□ Diabetes
□ Thyroid problems
□ Physical or Emotional trauma
Other ____________________________________________________________________________________
Did the mother use any of the following during the pregnancy? If yes, please list.
□ Tobacco
□ Alcohol
□ Recreational drugs: _____________________________________________
□ Prescription medications: __________________________________________________________________
□ Over-the-counter medications: ______________________________________________________________
□ Supplements: ____________________________________________________________________________
□ Other: __________________________________________________________________________________
Birth History
Term length: □ Full
□ Premature ___________weeks
□ Late ___________weeks
Length of labour: ______________
Weight at birth
Any complications? _________________________________________________________________________
_________________________________________________________________________________________
Was the birth: □ Vaginal
□ C-section
□ Induced
□ Vacuum or Forceps
□ Anesthesia used
Did the child experience any of the following at or shortly after birth?
□ Jaundice
□ Rash
□ Seizures
□ Birth injuries ______________________________________________________________________
□ Birth defects ______________________________________________________________________
□ Other ____________________________________________________________________________
Diet
How was your infant fed?
□ Breastfed How long? ______________
□ Formula Milk/Soy/Other How long? ___________
□ Other ____________________________________________________________________________
What foods were introduced before 6 months? (please list approximate month as well)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4
6-12 months?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did your child ever experience colic? Y N
How severe? □ Mild □ Moderate
□ Severe
Does your child have any food allergies or intolerances? Please list.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Does your child have any dietary restrictions (religious, vegetarian/vegan, etc.)?
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe a typical day’s diet:
Breakfast __________________________________________________________________________________
Lunch _____________________________________________________________________________________
Dinner _____________________________________________________________________________________
Snacks _____________________________________________________________________________________
Beverages and total quantity ___________________________________________________________________
Health and Development
How was your child’s health in the first year? □ Poor
At what age did your child first:
Sit up ______________
Crawl ______________
□ Fair □ Good
□ Excellent □ Unknown
Walk _____________
Talk ______________
5
Consent to treat a Minor
Patient Information:
First Name: __________________________________________ Last Name: ____________________________________
Date of birth: ___________________________________ Age: ________________________
I, _______________________________________________, authorize, Dr. Jennifer Corey/Dr. Gail Sauer, doctor of
naturopathic medicine, who has been engaged by me to examine and administer naturopathic care and treatment to
__________________________________ whose relationship to me is as a _____________________________________.
I have been given an explanation of and understand the nature of the naturopathic medical care and treatment. I
authorize Dr. Jennifer Corey/Dr. Gail Sauer, naturopathic doctor, to take whatever measures she considers necessary or
desirable in connection with such naturopathic care and treatment.
DATED in Markham, Ontario, this _________________________________________________ (month/day/year).
Parent or Guardian of Minor _________________________________________________
(Print name)
Parent or Guardian Signature _________________________________________________
Naturopathic Doctor Signature __________________________________________________
Dr. Jennifer Corey/Dr. Gail Sauer
6