tel: (905) fax: (905) CHILD Questionnaire (to be answered by the mother if possible)
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1 70 Queen St. S. Mississauga Ontario L5M 1K4 tel: (905) fax: (905) CHILD Questionnaire (to be answered by the mother if possible) Child s Name: Parents: Address: Phone: (day) (eve) Parents marital status: Date of Birth: Age: Birth weight (kg): Height (inches): Weight (lbs): % ile (if known) 1. What is the child s chief complaint (CC)? 2. When did this problem begin? What happened in your life around that time? What do you think caused it? 3. What aggravates the CC? (certain types of foods or weather, movement, light, noise, heat/cold, being at the seashore or anything else that you can think of) 4. At what time of the day or night is CC the worst? Specify an hour if you can. 5. What symptoms can you identify that accompany the CC? 6. What was your predominant emotional state when pregnant with this child? 7. During the pregnancy, did you suffer any particular shocks or traumas or losses? 8. Did you take any drugs? 9. How did your food cravings and aversions change during pregnancy? 10. Were there any particular complications at birth? 11. At what age did the child reach these stages: weaning closing of fontanels first milk teeth talking toilet training first permanent teeth crawling walking
2 12. How did the child react to these situations? Please try to think of mental and emotional reactions as well as any physical symptoms that may have developed. Vaccinations Birth of younger sibling Starting day care regularly First day at school Spending the night with a friend Travelling with the family Going away to camp etc. without the family 13. How many rounds of antibiotics has the child had, and for what? 14. Any skin conditions treated with cortisone cream? 15. Did the child suffer from a childhood disease with very severe symptoms? (measles, chickenpox, German measles, croup, mumps, etc.) 16. When ill or upset, does the child tend to cling to you or want to be left alone? 17. What is the child s behaviour in playing with other children? Does it make a difference if the other kids are older or younger? 18. What feedback do you get from your child s teachers about behaviour in class? 19 What pets do you have, and what is your child s attitude towards them?
3 20. a) What types of food does your child crave? Please be as specific as possible and list as many as you can. b) What types of food does she/he refuse to eat? c) What types of food does your child react badly to, whether physically (bloating, diarrhea, etc.) or behaviourally, and what are the reactions? 21. Any fears that are unusual for a child of your child s age (of the dark, being alone, lightning, thunder, etc.) Are there nightmares? 22. Is the child chilly? Is there excessive perspiration on the head and/or feet? 23. Is the child very affectionate when not sick? 24. Is the child unusually sympathetic (showing concern for the suffering of other children, animals, etc.)? 25. Does the child like music? What kind? Like dancing? Do symptoms (like restlessness) improve with music? 26. Is the child obstinate? How is this expressed? 27. Is the child fastidious? 28. Is the child sensitive to criticism and reprimand? 29. Can you think of any unusual or distinctive things about your child behaviour, fears, fantasies, desires, attachments, preferences in clothing, etc.? 30. Give a timeline for the child with all possible traumas, diseases, important events, deaths in the family. Describe the reaction of your child towards these events.
4 P E D I A T R I C F O R M To be used for children 12 years of age or under, and in conjunction with all other forms. Child s Name: Date: Age: Date of Birth: Sex: F M SYMPTOMS: (mark C for current and P for past symptoms) Abdominal pain Excessive fatigue Nightmares Acid reflux Excessive perspiration Night sweats Anemia Flat feet No appetite Bad breath Frequent headaches Nosebleeds Bed wetting Gas Painful urination Bleeding gums Hearing loss Parasites Blood in urine Heart murmur Psoriasis Body odour High fevers Rash Bruises easily Hives Sensitive to light Canker sores Hyperactivity Sleep problems Changes in appetite Itchy anus Stomach aches Congestion Itchy nose (or picks nose) Sore throat Constipation Itchy vagina Teeth grinding Cough Jaundice Talks in sleep Cries easily Joint pains Walks in sleep Diarrhea Migraines Weight gain Dizzy spells Motion sickness Weight loss Dry Skin Nervousness Wheezing Eczema Vomiting spells For Office Use Only: MEDICAL HISTORY: (check all that apply) ADD/ADHD Dental problems Neural Tube Defect Allergies (environmental) Developmental problems Pneumonia Allergies (food) Ear infections Rubella Asthma Frequent colds Rheumatic Fever Autism Impaired speech Scarlet Fever Bronchitis Measles Tonsillitis Chicken Pox Meningitis Whooping cough Croup Mumps Other (specify): Pg. 1 of 3, 08/09
5 Nutritional Supplements (please list). Include herbal and homeopathic as well. For Office Use Only: MEDICATIONS. (check all that apply, and indicate the length of time the child received each medication. Antacids Declectin Methylphenidate (Ritalin) Antibiotics Decongestant Oral Steroids Antidepressants Dextroamphetamine (Dexedrine, Dextrostat, Adderall) Pemoline (Cylert) Anti-Histamine Epilepsy medication Tylenol Aspirin Ibuprofen Others (please list) Clonidine Inhaled Steroids Are you aware of any allergies to medications? IMMUNIZATIONS: (check all that apply) Diptheria Influenza IPV (Polio) DPT Hemophilus Hepatitis Hib (Hemophilus Influenza) Measles MENI (Menigococcal disease) MMR (Measles, Mumps, Rubella) Mumps PNEU (Pneumoccocal disease) Small pox Tetanus VAR (Varicella or chicken pox) Were there any reactions to immunization(s)? If so, at what age? Pg. 2 of 3, 08/09
6 MOTHER S HEALTH DURING PREGNANCY: (check all that apply) Alcohol, Cigarettes, Drug Consumption Gestational Diabetes Stress For Office Use Only: Anemia Hypertension Thyroid problems Bleeding Nausea Uterine infection Dental problems Diabetes Physical or Emotional Trauma Pre-eclampsia Other (specify): MEDICATIONS WHILE PREGNANT: MEDICATIONS WHILE NURSING (Mother): TERM: Full Premature Late Weight at birth lb LABOR & DELIVERY: Was pregnancy induced? Vaginal C-Section Complications during labor? Medications during or after labor? FEEDING: Breast fed Bottle fed When was formula started? When were solid foods first introduced? What were the first foods introduced? Did your baby have any of the following problems? Jaundice Blue Baby Colic Diarrhea Thrush Pg. 3 of 3, 08/09
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