Pediatric Medical Questionnaire

Transcription

1 Turnpaugh Health and Wellness Center Pediatric Medical Questionnaire About You Last time child had blood work done and with which physician. Please provide a copy of all bloodwork, images, and records Birth Date Patient Name (MM/DD/YYYY) Age Sex Male Female Grade in School: Mother s Name and Occupation Father s Name and Occupation Parents are: Married Separated Divorced Living together Other _ Reason for office visit Has Child been seen by any other doctors for this concern? Yes Past _ Name of pediatrician and their location and phone number List all child s past medical problems, diagnosis, or suspected problems with approximate date: List all medicines, vitamins and supplements child is currently using: info@drchristurnpaugh.com Office Fax drchristurnpaugh.com Turnpaugh Health and Wellness Center 310 Lambs Gap Road Mechanicsburg, PA of 10

2 Previous Medical History Early Childhood Illnesses Number of earaches in the first two years: Number of other infections in the first two years: Number of times you had antibiotics in the first two years of life: Number of courses of prophylactic antibiotics in the first two years of life: First antibiotic at months First illness at months Hearing tests normal: Yes t tested Vision tests normal: Yes t tested Speech impediments: Yes Past Learning disabilities: Yes Past Vaccination History MMR: Yes Some Hib: Yes Some Hep B: Yes Some DPT: Yes Some Polio: Yes Some Chicken pox: Yes Some Other: Any reactions to vaccinations? Allergies Medications/supplement/Food Reaction Complaints/Concerns What do you hope to achieve in your visit with us? If you had a magic wand and help your child in three ways, what would they be? When was the last time you felt your child was well? Did something trigger your child s change in health? Is there anything that makes your child feel worse?_ Is there anything that makes your child feel better? _ Please list all current and ongoing problems in order of priority: Describe problem Mild Moderate Severe Prior treatment/approach Excellent Good Fair Example: Difficulty maintaining attention X Elimination diet X 2 of 10

3 Medical History Diseases/diagnoses/conditions Check appropriate box and provide date of onset Gastrointestinal Irritable Bowel Syndrome Inflammatory Bowel Disease Crohn s Ulcerative Colitis Gastritis or Peptic Ulcer Disease GERD (reflux) Celiac Disease Other Current Past Cardiovascular Heart disease Elevated cholesterol Hypertension (High blood pressure) Rheumatic Fever Mitral Valve Prolapse Other Current Past Metabolic/Endocrine Type 1 Diabetes Type 2 Diabetes Hypoglycemia Metabolic Syndrome (Insulin resistance or pre-diabetes) Hypothyroidism (Low thyroid) Hyperthyroidism (Overactive thyroid) Endocrine problems Polycystic Ovarian Syndrome (PCOS) Weight gain Weight loss Frequent weight fluctuations Bulimia Anorexia Binge eating disorder Night Eating Syndrome Eating disorder (non-specific) Other Current Past Cancer Current Past Genital and Urinary Systems Kidney stones Urinary tract infections Yeast infections Other Current Past Current Past Never Musculoskeletal/Pain Arthritis Fibromyalgia Chronic pain Other Current Past Inflammatory/Autoimmune Chronic Fatigue Syndrome Autoimmune Disease Rheumatoid Arthritis Lupus SLE Immune Deficiency Disease Severe Infectious Disease Poor immune function (frequent infections) Food allergies Environmental allergies Multiple chemical sensitivities Latex allergy Other Current Past Respiratory Diseases Frequent ear infections Frequent upper respiratory infections Asthma Chronic Sinusitis Bronchitis Sleep Apnea Other Current Past Skin Diseases Eczema Psoriasis Acne Other Current Past Neurologic/Mood Depression Anxiety Bipolar Disorder Schizophrenia Headaches Migraines ADD/ADHD Sensory Integrative Disorder Autism Mild cognitive impairment Multiple Sclerosis ALS Seizures Other neurological problems Other: 3 of 10

4 Previous Evaluations Check box if yes and provide date Full physical exam Psychological evaluations Wechsler Preschool & Primary Scale of Intelligence Speech and language evaluations Genetic evaluation Neurological evaluations Gastroenterology evaluations Celiac/gluten testing Allergy evaluation Nutritional evaluation Auditory evaluation Vision evaluation Osteopathic Acupuncture Physical therapy Occupational therapy Sensory integration therapy Language classes Sign language Homeopathic Naturopathic Craniosacral Chiropractic MRI CT scan Upper endoscopy Upper G.I. series Ultrasound Other Injuries Back injury Neck injury Head injury Broken bones Other Surgeries Appendectomy Circumcision Hernia Tonsils Adenoids Dental surgery Tubes in ears Other BLOOD TYPE: A B AB O Rh+ Unknown HOSPITALIZATIONS Date ne Reason COMMENTS Immunizations Is your child up to date with immunizations? Yes Do you feel immunizations have had an impact on your child s health? Yes If relevant, attach a copy of your child s immunization record or see addendum. Psychological Has your child experienced any major life changes that may have impacted his/her health? Yes Has your child ever experienced any major losses? Yes Stress/coping Have you ever sought counseling for your child? Yes Is your child or family currently in therapy? Yes Describe: Does your child have a favorite toy or object? Yes Does your child practice stress release methods? Yes If yes, then check all that apply: Yoga Meditation Imagery Breathing Tai chi Prayer Other: Has your child ever been abused, a victim of a crime, or experienced a significant trauma? Yes 4 of 10

5 Sleep/Rest Average number of hours your child sleeps per night: Greater than Less than 8 Does your child have trouble falling asleep? Yes Does your child feel rested upon awakening? Yes Does your child snore? Yes Roles/Relationship List family member and relationship Age Gender Who are the main people who care for your child? _ What are their employment/occupation? Resources for emotional support: Check all that apply Spouse Family Friends Religious/Spiritual Pets Other: _ Gynecologic History (for f es only) Age at first period: Menses Frequency: Length: Pain? Yes Clotting? Yes Has your period ever skipped? Yes If yes, For how long? Last menstrual period: Does your child use contraception? Yes Condom Diaphragm IUD Partner vastectomy Use of hormonal contraception such as: Birth control pills Patch Nuva Ring How long? GI History Has your child travelled to foreign countries? Yes If yes, where? _ Wilderness camping? Yes If yes, where? Has your child ever had severe: Gastroenteritis Diarrhea Dental History Silver mercury fillings How many? Gold fillings Root canals Implants Tooth pain Bleeding gums Gingivitis Problems with chewing Does your child floss regularly? Yes Patient Birth History Mother s past pregnancies Check box if yes and provide date Number of: Pregnancies: Live births: Miscarriages: Mother s Pregnancy Check box if yes and provide description is applicable Difficulty getting pregnant (More than six months) Infertility drugs used (specify) In vitro fertilization Drink alcohol Drink coffee Smoke tobacco Take Progesterone Take prenatal vitamins Take antibiotics Take antibiotics during labor Take other drugs (specify) Excessive vomiting or nausea (more than three weeks) Have a viral infection Have a yeast infection Have amalgam fillings put in teeth Have amalgam fillings removed Number of fillings in teeth when pregnant Have bleeding? If so, which months? Have birth problems Group B strep infection Have a C-section because of: 5 of 10

6 Mother s Pregnancy (continued) Use induction for labor (such as Pitocin) Have anesthesia? If so, list type Use oxygen during labor Have an x-ray How many shots of Rhogam while pregnant? How many shots of Rhogam during labor? Gestational diabetes High blood pressure (pre-eclampsia) High blood pressure/toxemia Have chemical exposure Father have chemical exposure Moved to a newly built house House painted indoors House painted outdoors House Exterminated for insects Total weight gain during pregnancy: lbs Total weight loss during pregnancy: lbs Please describe diet during pregnancy: Please describe labor: _ Perinatal Pregnancy Duration (Please indicate at what week your baby was born) (Full term) Very active before birth? Yes Hospital/birthing center? Yes Needed newborn special care? Yes Appeared healthy? Yes Easily consoled during first month? Yes Antibiotics first month? Yes Experienced no complications first month of life? Yes Birth weight and Apgar Weight at birth: lbs, oz Apgar score at one minute: Apgar score at ten minutes: Description of Developmental Problems If your child has developmental problems, at what age do they occur? 0-1 months 2-6 months 7-15 months months After 24 months In this impression shared among parents and others caring for the child? Yes Does this impression, as to the timing of onset, differ among parents and others caring for the child? Yes Is the impression, as to the timing of onset, weak? Yes Or is the impression strong? Yes Developmental History Please indicate the approximate age in months for the following milestones (example: walking 14 months): Sitting up Crawl Pulled to stand Potty trained Walked alone Dry at night First words ( mama, dada etc.) Spoke clearly Lost language Lost eye contact 6 of 10

7 MSQ - Medical Symptom Toxicity Questionnaire Name Date _ (MM/DD/YYYY) The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying cause of illness, and helps track your child s progress over time. Rate each of the following symptoms based upon your child health profile for the past 30 days. If you are taking after the first time, record your child s symptoms for the last 48 hours ONLY. Point Scale 0 = Never or almost never have the symptom 1 = Occasionally have the symptom, effect is not severe 2 = Occasionally have the symptom, effect is severe 3 = Frequently have the symptom, effect is not severe 4 = Frequently have the symptom, effect is severe DIGESTIVE TRACT Nausea or vomiting Diarrhea Constipation Bloated feeling Belching or passing gas Heartburn Intestinal/stomach pain EARS Itchy ears Earaches, ear infections Drainage from ear Ringing in ears, hearing loss EMOTIONS Mood swings Anxiety, fear or nervousness Anger, irritability or aggressiveness Depression ENERGY/ACTIVITY Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness EYES Watery or itchy eyes Swollen, reddened or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision (Does not include near or farsightedness HEAD Headaches Faintness Dizziness Insomnia HEART Irregular or skipped heartbeat Rapid or pounding heartbeat Chest pain JOINTS/MUSCLES Pain or aches in joints Arthritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tiredness LUNGS Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing MIND Poor memory Confusion, poor comprehension Poor concentration Poor physical coordination Difficulty in making decisions Stuttering or stammering Slurred speech Learning disabilities MOUTH/THROAT Chronic coughing Gagging, frequent need to clear throat Sore throat, horses, loss of voice Swollen/discolored tongue, gums, lips Canker sores NOSE Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formation SKIN Acne Hives, rashes, or dry skin Hair loss Flushing or hot flushes Excessive sweating WEIGHT Binge eating/drinking Craving certain foods Excessive weight Compulsive eating Water retention Underweight OTHER Frequent illness Frequent or urgent urination Gentle itch or discharge GRAND TOTAL Key to questionnaire Add individual scores and total each group. Add each group scores and give a grand total. Less than 10 = Optimal = Mild toxicity = Moderate toxicity Over 100 = Severe toxicity 7 of 10

8 Medications CURRENT MEDICATIONS Medication Dose Frequency Start Date (month/year) Reason for use PREVIOUS MEDICATIONS: Last 10 years Medication Dose Frequency Start Date (month/year) Reason for use NUTRITIONAL SUPPLEMENTS (VITAMINS/MINERALS/HERBS/HOMEOPATHY) Medication Dose Frequency Start Date (month/year) Reason for use Has your child s medications or supplements ever caused them unusual side effects or problems? Yes Describe: Has your child had prolonged regular use of NSAIDS (Advil, Aleve, etc.), Motrin, Asprin? Yes Has your child had prolonged regular use of Tylenol? Yes Has your child had prolonged regular use of acid blocking drugs (Tagamet, Zantac, Prilosec, etc.)? Yes Frequent Antibiotics > 3 times/year Yes Longterm Antibiotics Yes Use of steroids (prednisone, nasal allergy inhalers) in the past Yes Use of oral contraceptives Yes 8 of 10

9 Family History Check family members that apply Mother Father Brother(s) Sister(s) Children Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Aunts Uncles Other Age (if still alive) Age at death (if deceased) ADHD ALS or other Motor Neuron Diseases Asthma Autism Auto Immune Diseases (such as Lupus) Bipolar Disease Breast or Ovarian Cancer Cancers Celiac Disease Colon Cancer Dementia Depression Diabetes Eczema / Psoriasis Environmental Sensitivities Food Allergies, Sensitivity, or Intolerances Genetic Disorders Heart Disease Hypertension Inflammatory Arthritis (Rheumatoid, Psoriatic, Ankylosing Sondylitis) Inflammatory Bowel Disease Irritable Bowel Syndrome Multiple Sclerosis Obesity Parkinson s Psychiatric Disorders Schizophrenia Stroke Substance Abuse (such as alcoholism) 9 of 10

10 Social History NUTRITION HISTORY Has your child ever had a nutrition consultant? Yes Has your child made any changes in your eating habits because of their health? Yes Describe: Does your child currently follow a special diet or nutritional program? Yes Check all that apply Low Fat Low Carbohydrate High Protein Low Sodium Diabetic Dairy Wheat Gluten Restricted Vegetarian Vegan Ultrametabolism Specific Program for Weight Loss/Maintenance Type: Other: Height (feet/inches): Usual Weight Range (+/- 5 lbs): Highest Adult Weight: Current Weight: Desired Weight Range +/- 5 lbs: Lowest Adult Weight: Weight Fluctuations (>10 lbs) Yes Body Fat % How often do you weigh your child? Daily Weekly Monthly Rarely Never Have you ever had your child s metabolism (resting metabolic rate) checked? Yes If yes, what was it? Do they avoid any particular foods? Yes If yes, types and reason If your child could only eat a few foods a week, what would they be? Do you grocery shop? Yes Do you read food labels? Yes If no, who does the shopping? Do you cook? Yes If no, who does the cooking? How many meals do you eat out per week? More than 5 meals per week Check all the factors that apply to your child s lifestyle and eating habits: Fast eater Erratic eating pattern Eat too much Late night eating Dislike healthy food Time constraints Eat more than 50% meals away from home Travel frequently Non-availability of healthy foods Do not plan meals or menus Reliance on convenience items Poor snack choices Significant other or family members don t like healthy foods Significant other or family members have special dietary needs or food preferences Love to eat Eat because I have to Have a negative relationship with food Struggle with eating issues Emotional eater (eat when sad, lonely depressed, bored) Eat too much under stress Eat too little under stress Don t care to cook Eating in the middle of the night Confused about nutrition advice Does your child smoke? Yes If yes, how much? Do your child drink? Yes If yes, how much? The most important thing I should change about my child s diet to improve their health is: 10 of THWC