Vicki Kobliner MS RDN phone fax Hollyhock Road Wilton, CT 06897
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1 1 INITIAL PEDIATRIC QUESTIONNAIRE PERSONAL INFORMATION: Child s First Name: Last Name: Middle Initial: Parents Names Home Address: Phones: (Home) (Cell) (Work) Birth Date: / / Sex: M F Height: Weight: lbs Child s Current Diagnosis (list all): Primary Care Physician: Name Phone: Address: Date of Last Physical: HEALTH INSURANCE INFORMATION: * Please note: Coverage for nutrition services is not guaranteed even I am a provider under your insurance plan.* Primary Health Insurance: ID/Group #: GENERAL: Referred by: Primary Goal SPECIALISTS (include MDs, naturopaths, homeopaths, therapists etc) NAME SPECIALTY PHONE NUMBERS CITY, STATE LAST VISIT
2 2 BIRTH and EARLY HEALTH HISTORY: Illnesses or complications during pregnancy Number of Dental Amalgams (mom) Medications taken during pregnancy or labor and delivery C-Section? Any complications after delivery? Please check any of the following childhood illnesses your child experienced: Frequent Ear, Throat or other Infections Colic Reflux Meningitis Asthma Chicken Pox Eczema Frequent Colds Other antibiotics or steroid medications frequently? Describe his/her stool pattern (frequency, color, odor, consistency) DIETARY/NUTRITIONAL/DIGESTIVE HISTORY: Breastfed Bottlefed How long? Type of Formula used Did your child have reflux, colic, spitting up etc in infancy? Describe any chronic gastrointestinal problems during infancy or present: Is your child currently following a special diet? Describe: Known food allergies Suspected food SENSITIVITIES Food CRAVINGS (e.g. bread, pasta, cheese, salty foods, sodas/coffee/tea with or without caffeine, alcohol, milk, etc):
3 3 Please list the foods and beverages normally consumed by your child in a typical three day period. DAY 1 Breakfast Morning Snack (s) Lunch Afternoon Snack (s) Dinner Other DAY 2 Breakfast Morning Snack (s) Lunch Afternoon Snack (s) Dinner Other DAY 3 Breakfast Morning Snack (s) Lunch Afternoon Snack (s) Dinner Other
4 4 FAMILY HISTORY: List any allergies, major illnesses, genetic diseases or problems (such as digestive issues or mental health problems) for each family member. Mother Father Maternal Grandparents Paternal Grandparents Other PAST MEDICAL HISTORY: Please list any major illnesses, injuries or surgeries CONDITION PAST TREATMENTS CURRENT TREATMENTS APPROXIMATE DATE (S) of TREATMENT CURRENTMEDICATIONS, VITAMINS, MINERALS, and OTHER NUTRITIONAL SUPPLEMENTS:
5 5 Please list any other medications taken in the past? Specifically indicate any frequent use of antibiotics and/or steroids in the past. VACCINATION HISTORY Please attach copy of child s vaccine records and list any adverse reactions.
6 6 Please mark which tests have been done and provide date and results. EVALUATION TEST DATE RESULTS (Normal, Abnormal) * Please send results/reports with this form * Blood Chemistry (Including Liver Function Tests) Blood Count (CBC) IgG Food Sensitivity Panel IgE Environmental Allergy Panel Hair Elements Urine Toxic Metals and Elements Homocysteine Folic Acid Serum Methylmalonic Acid Immune Profile Urine Organic Acids Amino Acids Plasma or Serum Zinc Plasma or Serum Copper RBC Elements Iron Studies (Ferritin, % Iron Saturation, TIBC, etc) Thyroid Panel (TSH, etc) Serum Vitamin Levels (Specify) Stool Culture Stool Ova and Parasites Uric Acid (blood or urine) OTHER
7 7 SIGNS and SYMPTOMS: Please check where appropriate. DESCRIPTION MILD MODERATE SEVERE DETAILS Fatigue Difficulty falling asleep Difficulty staying asleep Early waking Nighttime waking Daytime sleepiness Night walking Nightmares Fever Heat intolerance Cold intolerance Flushing Headache Specify type Low self esteem Trouble remembering Seizures Anxiety Irritability Depression Fainting Difficulty with concentration Difficulty with balance Numbness/Tingling Mood swings Conjunctivitis Sensitive to lights or loud noises Sore throats Congestion Dark circles/ puffiness under eyes Sinus infections Post nasal drip Loss of smell Loss of taste Bad breath Nose bleeds Hoarseness Cough Dry Cough Productive Wheezing Seasonal Allergies Poor appetite Bad teeth Dry mouth Geographic tongue (map-like rash on the tongue) Cold sores
8 8 Cracking at corner of lips Nausea Vomiting Abdominal pain Bloating Belching Diarrhea Constipation Undigested food in stool Mucous in stool Blood in stool Difficulty swallowing Eczema Hives Rash Athletes foot Acne Easy bruising Ears get red Sensitive to bug bites Pale skin Dry skin Itchy skin Cracking or peeling of feet Cracking or peeling of hands Nail biting Soft nails White spots on nails Thickening of nails Fungus on nails Ridges on nails Pitting of nails Bed-wetting Dry lips Teeth grinding Psoriasis Strong body odor OCD behavior Reflux Dry lips Night blindness OTHER OTHER OTHER OTHER
9 9 B complex Insomnia Dermatitis, patchy skin Sugar craving Irritability, depression Thiamin Anxiety, Fear Sleep disturbance Irritability Poor coordination Increased Alcohol/sushi swelling B2 (riboflavin) Neuropathy dermatitis lack of taste, stomatitis Cracked lips watery or bloodshot eyes B3(Niacin) abdominal discomfort Nausea or diarrhea Depression, poor memory, confusion rough skin canker sores bad breath B5 (pantothenic acid) burning or numb feet cramps, abdominal distress acne poor coordination hair loss B6 acne dermatitis, muscle weakness irritability, depression poor immunity tooth decay fatigue Oxalates Anemia Folic Acid diarrhea sulfa drugs anemia B12 Poor memory vegetarian diet Viral infection, shingles depression poor balance Biotin muscle pain depression hair loss dermatitis Calcium brittle nails cramps depression tooth decay insomnia high soda intake Choline/Inositol Depression Memory loss fat intolerance Chromium anxiety fatigue poor glucose control Copper anemia depression diarrhea fatigue hair loss bruising Copper excess anxiety ringing in ears sensitive to metals poor concentration Iodine weight gain hypothyroidism dry skin and hair puffy face poor memory Iron Anemia Brittle nails Confusion, poor memory Headaches Mouth/tongue sores Magnesium constipation muscle spasms insomnia anxiety hyperactivity restless leg teeth grinding headache/migraine Manganese dizziness ringing in ears poor glucose control Seizures Mottled skin tone Molybdenum Acne PMS Migraines Caffeine intolerance sulfite/nitrite intolerance
10 10 Potassium Diarrhea edema difficulty breathing muscle cramps Selenium pancreatic insufficiency immune impairment Sodium Cramps constipation PMS, morning sickness Zinc Acne brittle nails depression delayed puberty poor growth hair loss impotence/infertility poor appetite low stomach acid Poor immunity White spots on nails Vitamin A Night blindness acne CF dry skin/hair infertility URI poor growth Vitamin C bleeding gums easy bruising poor wound healing loose teeth Wrinkled skin joint pain arms Vitamin D burning mouth diarrhea insomnia seasonal depression psoriasis scalp sweating poor coordination Vitamin E altered gait poor reflex CF, Infertility dry, itchy skin breast cysts Vitamin K bleeding ulcers nose bleeds, bruising liver or kidney disease Essential Fatty Acids Dry, flaky skin cracking peeling hands/feet clear bumps on upper dandruff/cradle cap splitting, dull nails ear wax acne excess thirst poor attention Pyroluria Poor dream recall white spots on nails skips breakfast sensitive to lights/noise histrionic/argumentative likes spicy foods Poor liver function sensitive to perfumes, chemicals, cigarettes headaches/migraines poor appetite Gluten intolerance low iron loose, unformed stools abdominal bloating floating stools itchy skin, psoriasis Candida Thrush antibiotic use chronic congestion poor concentration bloating, gassiness sugar cravings eczema, psoriasis attention problems anal itching Parasites abdominal bloating or discomfort food sensitivities tooth grinding psoriasis, eczema, hives fatigue anal itching loose/foul stools
11 11 Describe any other symptoms you would like me to know about: List any other history, pertinent thoughts or questions you want to address:
* Above for office use only * Child s First Name: Last Name: Middle Initital: Primary Health Insurance: Primary Care Physician: Name
1 Today s Date: Date of Initial Consult: * Above for office use only * PERSONAL INFORMATION: Child s First Name: Last Name: Middle Initital: Parents Names Home Address: Email: Phones: (Home) (Cell) (Work)
Vicki Kobliner MS RDN phone fax Hollyhock Road Wilton, CT 06897
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Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:
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