Pediatric Intake Form

Transcription

1 Pediatric Intake Form Welcome. This intake will help us to discover the root cause of your health concerns. If any of these questions are difficult for you to answer, please let Dr. McAllister know. Please fill out as much as possible and mail, or fax the intake to our office prior to your first visit. If this is not possible, bring in the completed form to your first visit. We look forward to meeting you. Name: Today s Date: Address: City: State: Zip: Gender: Age: Grade in School Date of Birth: Mother s name and occupation: Father s name and occupation: Parents are (circle one): Married Separated Divorced Other Parent Phone (h): (c): (w): Address of Parent: Preferred method of contacts: Leave a Message: Number of sibling and names: Pediatrician: Address: Office number: How did you hear about Dr McAllister or BALANCED WELLNESS, LLC? Please list your chief health concerns in order of importance: 1: 2: 3: 4: 5: How long? What would you most like to accomplish on your initial visit?

2 Page: 2 Medications / Supplements Please list prescription medication, over-the counter medications, vitamins, herbs or other supplements you are taking. Medication/ Supplement Name Dosage Why are you taking this? Medical History Have you ever been treated with the follow? Y= currently using, N= never used, P=in the past have used Antibiotics P Number of times Length of treatment Thyroid Medication P Pain Relievers P Cortisone/Steroids P Laxative/stool softeners P Antacids P Antihistamines P Please list all known allergies to: (please describe the adverse reaction). Medications (prescription, over the-counter, recreational), Supplements Vaccinations, Food and Environmental allergies What hospitalizations have you had? When For what reason

3 Page: 3 Family History (if known) Mother Father Siblings Age if Living Age if Deceased Ailment Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Has a blood relative ever had any of the following? Heart Disease /Stroke High Blood pressure Diabetes Thyroid Disease Allergies / Hay fever Asthma Cancer Tuberculosis Kidney Disease Depression / Mental illness Alcoholism / Drug Abuse Osteoporosis Arthritis Which relative? Have you had the following vaccination? Y= yes, N=none, S=some but not the whole series MMR S Chickenpox S DPT S Hib S HepB S Polio S Other Any reaction to the vaccination? explain

4 Page: 4 Birth History Mother s Age at conception Child s birth order (1 being oldest) Number of weeks of pregnancy at birth Length of labor Vaginal or caesarean birth V C Any Complications, explain Health of baby at birth Was the child breastfed For how long Was the child ever on formula For how long, brand used When was the child introduced to solid food When did the child develop teeth When did the child start to walk Talk Review of Systems: Y=have currently, N=never, P= in the past General Fever P Chills P Early puberty P Fatigue P Frequent colds P Skin Rashes P Eczema/Hives P Acne/Boils P Itching P Cradle cap P Diaper Rash P Dry Skin P Lumps/Warts P Bruise Easy P Nose and Sinuses Nose bleeds P Frequent Colds P Stuffiness P Hay fever P Sinus Problems P Allergies P Post nasal drip P Neck Lumps P Swollen glands P Goiter P Pain P Frequent Cracking P Respiratory Cough P Wheezing P Difficultly Breathing P Bronchitis P Asthma P Pneumonia P Head / Eyes / Ears / Throat Head Injury P Headaches P Migraines P Eye pain P Glasses/Contact P Tearing P Ringing P Earache P Dizziness P Cavities P Canker Sores P Dental Exam

5 Page: 5 Gastrointestinal Nausea P Vomiting P Constipation P Diarrhea P Blood in Stool P Colic P Jaundice P Stomachaches. P Finicky eater P Number of Bowel Movements Daily Formed Cardiovascular Palpitations P Murmur P Anemia P Neurological Seizures P Hyperactivity P Numbness P Musculoskeletal Growing pains P Muscle spasms P Muscle cramps P Broken bones P If yes when Immune Chronic infections P Frequent antibiotics P Frequent colds/flu P Cold sores P Swollen glands P Slow wound healing P Frequent sore throat P Has there ever been an event or sickness that you have never fully recovered from? explain Urinary Pain on urination P Increased Frequency P Frequent infections P Bed-wetting P Endocrine Sluggish after eating P Generally feel hot P Generally feel cold P Wake from sleep rested P Mental fog P Diabetes P Mental Emotional Depression P Mood Swings P Panic Attacks P Anxiety/ Nervousness P Disobedient P Phobias / Fears P History of Abuse P Tantrums P Prolonged grief or sadness P Nightmares P What was the most stressful event in your life? Is it still affecting you?

6 Page: 6 Diet How many meals do you eat daily? How much water, do you drink daily? How many sodas, coffees, or teas do you drink per week? How many times per week do you eat- Dairy Red meat Fish Fruit Vegetables How often do you eat out or order take out? What foods do you crave? Do you have dietary restrictions? Environmental Exposure Have you ever lived in a house with lead paint? Have you ever experienced health problems after putting down new carpets, painting or doing renovations? Are you sensitive to perfume, gasoline or other vapors? Have you ever lived near a refinery or polluted area? Have you ever lived in a home more than 50 years old? Do you have mercury dental fillings? How many Have you had any dental root canal procedures? Do you have any surgical implants? Do you live near power lines? Do you spray pesticides or herbicides around the house? D o you use environmental safe cleaning products? Personal Rate your energy level between 1 and 10 (10= the most energetic) Rate your stress level between 1 and 10 (10 is the most stressful) What time of day is your best energy? What time of day is your worst energy? How many hours do you sleep a night? Uninterrupted? Are you exposed to secondhand smoke? How often do you exercise? What kind? How much time to you spend out door per week? Do you have a spiritual practice or religion? Thank you for taking the time to fill out this form. We look forward to seeing you! Parent s Signature Date