The Center For Healthy Living & Longevity Keri Topouzian, D.O. Fax:
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1 The Center For Healthy Living & Longevity Keri Topouzian, D.O. Fax: Pediatric Health Questionnaire Today s Date: / / BLOOD TYPE: Patient Name: Birth date: / / Age: Mother s Name Father s Name Address: City: State: Zip: Home Phone: Cellular Work: Type of Health Insurance: PPO HMO Other Height: Weight: Siblings, gender & Ages List of those living in primary home Paternal Family Medical Conditions / Diseases: Autoimmune Alcoholism or addictions Mental or emotional illness Depression Bipolar Anxiety Other: Psychotropic Medications: Maternal Family Medical Conditions / Diseases Autoimmune Alcoholism or addictions Mental or emotional illness Depression Bipolar Anxiety ADHD Other: Personality disorder Epilepsy Thyroid disease - goiter, nodules, low thyroid Learning disabilities Psychosis Obsessive compulsive disorder ADHD Personality disorder Epilepsy Thyroid disease - goiter, nodules, low thyroid Learning disabilities Psychosis Obsessive compulsive disorder Night Blindness? Psychotropic Medications: Amalgam Fillings: How many: When Placed: Any amalgam fillings placed in mother during pregnancy or breast feeding? Can your child swallow capsules yet?
2 Mother s age at delivery: Was child born within 2 weeks of the due date: Vaginal or C-Section: Any complications with labor or delivery: Birth weight: Did the child have: Breathing problems Infection Jaundice Feeding Problems Did baby go home with mother: Breast fed/how long: Vaccination history and describe and adverse reactions or changes in behavior after receiving: Describe general development of your child to date: Eating patterns: Sleep patterns: History of antibiotic use since birth: Surgeries, tubes in ears:
3 Seizures: Age of onset, type, accompanied by fever, timing regarding illness, injuries or vaccinations: Any regression in speech: Current speech ability: Schooling academics: Disruptive antisocial behavior in public: Learning disorders, delays: Teacher comments/reactions Describe general personality: Hyper or hypoactive: Favorite foods: Most disliked foods:
4 List any laboratory studies undertaken and results: List any Stomach problems, stool patterns, colic, diahrea, heartburn, constipation, etc. List any special diets and the reaction/results: Does child use artificial sweeteners? Yes What type? No Carbonated beverages? Yes How many per day? No Do you have any pets? Yes Type? No Have you lived or traveled outside of the United States? If so, when and where? Allergies: Please check all that apply Penicillin morphine dye allergies seasonal (pollen) allergies Codeine aspirin nitrate allergy no known allergies sulfa drugs food allergies pet allergies other: Please describe the allergic reaction you experienced and when it occurred: Over-the-counter (OTC) issues: Please check all products that you used occasionally or regularly. pain reliever combination products (cough & cold reliever, Triaminic DM ) aspirin sleep aids (Excedrin PC, Unisom, Sominex, Nytol ) acetaminophen (Tylenol ) antidiarrheals (Imodium, Pepto Bismol, Kaopectate ) ibuprofen (Motrin IB ) Laxatives / stool softener (Doxidan, Correctol ) naproxen (Aleve ) Diet aids / weight loss products (Dexatrim ketoprofen (Orudis KT ) antacids (Maalox, Mylanta ) cough suppressant (Robitussin DM ) acid blockers (Tagamet HB, Pepcid C, Zantac 75 ) antihistamine (Benadryl, Chlor-Trimeton ) others: decongestant (Sudafed )
5 Nutritional / Natural Supplements: Please check the products you are using & list below vitamins (multiple or single vitamins, i.e. B complex, E, C, carotene) minerals (calcium, magnesium, chromium, colloidal minerals, single minerals) herbs (Ginseng, Ginkgo Biloba, Echinacea, herbal medicinal teas, tinctures, etc.) enzymes (digestive formulas, papaya, bromelain, CoEnzyme Q10, etc.) nutrition / protein supplements ( shark cartilage, protein powders, amino acids, fish oils) others (glucosamine, etc.): Vitamin/Mineral Supplement Name Date Started Dosage Describe eating habits including the times you usually eat: (include deserts) Breakfast Lunch Dinner Type of Snacks Crave any foods? Current Prescription Medications: Medication Name Reason for Taking? Strength Date Started Dental History How many Silver/Mercury Amalgams do you have? Recent cavities, crowns, root canals? Describe: History of any Gum Disease? Describe: One more page to go
6 Describe your problems that lead you to this consultation: What are your goals with this consultation? Please write down any specific questions you may have. If possible, please bring in, fax or mail any recent lab work or other test results. Thank you!
Mike Dandurand RPh. PharmD, CGP Phone # Fax # Pharmacist Progress Notes
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Cough Suppressant (example: Robitussin DM ) Acid Blockers (examples: Tagamet HB, Pepcid AC, Zantac 75 )
$200NonRe f undabl e De pos i tdueatappoi nt me nt Sc he dul i ng! 4. Allergies: Please check all that apply: penicillin morphine dye allergies pet allergies codeine aspirin nitrate allergy seasonal (pollen)
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What do you feel are your child s strengths at this time?
PEDIATRIC MEDICAL QUESTIONNAIRE Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care
PEDIATRIC INTAKE. Child s Name: Date: Name of Parent(s)/Legal Guardians: Relationship to child: Address: City: State: Zip Code:
PEDIATRIC INTAKE I appreciate your willingness to fill out this form as completely as possible. It is invaluable information for developing a treatment plan tailored to your child s individual needs. General
PEDIATRIC HEALTH HISTORY FORM. Patient Name: DOB: / / Height: Weight: Lbs. Parent (s) Name: Address:
PEDIATRIC HEALTH HISTORY FORM Patient Name: Date: DOB: / / Height: Weight: Lbs Parent (s) Name: Address: Is there any other information about your child s health that you would like me to know? (Please