* Above for office use only * Child s First Name: Last Name: Middle Initital: Primary Health Insurance: Primary Care Physician: Name
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1 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: Phones: (Home) (Cell) (Work) Childs Age: Birth Date: / / Sex: M F Height: Weight: lbs HEALTH INSURANCE INFORMATION: * Please note We do not accept any health insurance. You are responsible for submitting your own claims. * Primary Health Insurance: ID/Group #: OTHER: Primary Care Physician: Name Phone: Address: Your Local Pharmacy: Name: Phone #: City, State: GENERAL: Referred by: What is your primary goal today? What are the biggest nutrition concerns regarding your child?
2 SPECIALISTS NAME SPECIALTY PHONE NUMBERS CITY, STATE LAST VISIT 2 NUTRITIONIST NAME PHONE NUMBERS CITY, STATE LAST VISIT NATUROPATH (S) and or HOMEOPATH (S) NAME PHONE NUMBERS CITY, STATE LAST VISIT EARLY HEALTH HISTORY: Illnesses or complications during pregnancy Medications taken during pregnancy or labor and delivery C Section? Any complications after delivery? Please check any of the following childhood illnesses: Frequent Ear, Throat or other Infections Colic Reflux Meningitis Asthma Chicken Pox Eczema Frequent Colds Other antibiotics or steroid medications frequently?
3 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: Have you tried: Gluten Free Casein Free Yeast Free Salicylate Free Atkins South Beach Low Phenols IgG reactive food avoidance Specific Carbohydrate Diet Low Protein Other Current diet % for the following: Organic/Fresh Food Processed Food Fast Food Other 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): * FOODS EATEN Place in appropriate column: FOOD DAILY > ONCE per Week RARELY NEVER USED TO EAT Cookies Candy Sweets in general Caffeine (soda, tea, coffee) Milk Specify Type (e.g. cow s, rice, soy, etc and whole, 2%, 1% or skim) 3 Cheese Ice Cream Salty Foods Meat Pasta Bread Specify Type Vegetables Fruits Fried Foods Grains
4 DIET/NUTRITIONAL HISTORY CONTINUED: Please list the foods and beverages normally consumed by your child in a typical three day period. Breakfast Morning Snack (s) Lunch Afternoon Snack (s) Dinner Other DAY 1 4 DAY 2 Breakfast Morning Snack (s) Lunch Afternoon Snack (s) Dinner Other DAY 3 Breakfast Morning Snack (s) Lunch Afternoon Snack (s) Dinner Other Describe his/her stool pattern (frequency, color, odor, consistency)
5 PAST MEDICAL HISTORY: Please list any major illnesses, injuries or surgeries CONDITION PAST TREATMENTS CURRENT TREATMENTS APPROXIMATE DATE (S) of TREATMENT 5 MEDICATIONS: What is your child taking NOW? NAME DOSAGE and # per day Good Response No Response Bad Response Bad then Good VITAMINS, MINERALS, and OTHER NUTRITIONAL SUPPLEMENTS: What is he/she taking NOW? NAME and FORM (eg. Calcium Carbonate vs. Calcium Citrate) DOSAGE (mg, mcg, IU, etc) and # per day Good Response No Response Bad Response Bad then Good Res.
6 Please list any other medications taken in the past? Specifically indicate any frequent use of antibiotics and/or steroids in the past. Also, please comment as to good, bad or no responses to each medication. Please ( ) substances taken in the past and mark appropriate reaction. 6 Taken In PAST SUPPLEMENT Multivitamin (Specify) DOSAGE (mg, mcg, IU, etc) And # per/day Good None Bad Good then Bad Vitamin A Vitamin C Vitamin E Vitamin B3 (Niacin) Vitamin B6 5 HTP/Serotonin Alpha Keto Glutarate DMG or TMG (circle) GABA Glutamine SAMe Taurine Calcium (Specify Type) Magnesium Selenium IV Immune Globulin Oral Immune Globulin Secretin (Specify form) Essential Fatty Acids (Specify) Probiotic (Specify brand) Pycnogenol Folic Acid B12 (Specify Form) Natural AntiBacterials (Specify)
7 Natural AntiFungals (Specify) 7 Natural AntiVirals (Specify) Vitamin D Vitamin K OTHER
8 FAMILY HISTORY: List any allergies, major illnesses, genetic diseases or problems (such as digestive issues or mental health problems) for each family member. ** If any family members are deceased, please also list their age at death and cause. Mother Father Siblings Maternal Grandparents Paternal Grandparents Others 8 HEALTH MAINTAINANCE UPDATE: *Please send results and/or reports with this form if appropriate. TEST DATE RESULTS COMMENTS Physical Examination 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
9 9 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
10 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 Cracking at corner of lips Nausea 10
11 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 Nancy H. O Hara, MD and Associates 11
12 Describe any other symptoms you would like us to know about? 12 List any other history, pertinent thoughts or questions you want to address:
Vicki Kobliner MS RDN phone fax Hollyhock Road Wilton, CT 06897
1 INITIAL PEDIATRIC QUESTIONNAIRE PERSONAL INFORMATION: Child s First Name: Last Name: Middle Initial: Parents Names Home Address: Email: Phones: (Home) (Cell) (Work) Birth Date: / / Sex: M F Height: Weight:
ADULT QUESTIONNAIRE:
** THIS FORM MUST BE RECEIVED BY OUR OFFICE BEFORE YOU CAN MAKE AN APPOINTMENT** Today s Date: Date of Initial Consult: * Above line for office use only * ADULT QUESTIONNAIRE: PERSONAL INFORMATION: First
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