PEDIATRIC HEALTH HISTORY FORM. Patient Name: DOB: / / Height: Weight: Lbs. Parent (s) Name: Address:
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1 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 include if this information can be discussed in front of your child.) What is your primary concern for your child s health? What additional concerns would you like to address? What expectations do you have for today s visit? At this present time, how committed are you to addressing the underlying symptoms that may relate to your child s lifestyle? (Please check your selection below) (0 = not committed and 10 = completely committed) Natural Integrative Healthcare Patricia L. Diefenbach, ND, MS, CNC, CNS Naturopathic Physician Diefenbach.ND@gmail.com Phone: (703)
2 MEDICAL HISTORY Who is your child s pediatrician? List all the medications that your child is taking (with doses) List all herbs/vitamins that your child is taking (with doses) List all allergies (food/environmental/drug) No Known List and date all surgeries, hospitalizations and major accidents Page 2 of 8
3 CHILDHOOD ILLNESSES Has your child ever experienced/been diagnosed or received treatment for the following? (Check all that apply) Scarlet Fever Measles Autistic Spectrum Disorder Chicken Pox German Measles Sore Throat/Infection (frequency ) Rheumatic fever Mumps # of Colds per year Scarlet Fever Diptheria Other Shingles Eczema Asthma Ear Infections (frequency ) Has your child had any of the following tests? (Check all that apply) Electroencephalogarm (EEG) When/Where: Psychological Evaluation Hearing Tests Speech/Language Tests Eye Exam When/Where: When/Where: When/Where: When/Where: Has your child had any of the following immunizations? (Check all that apply that had adverse reactions) Polio Tetanus Measles/Mumps/Rubella Pertussis Diptheria Influenza Hep B HPV Chicken Pox Hib Rotavirus How was your child born? Vaginal Cesarean Any complications? (Premature, overdue, etc) Was your child breast-fed? Yes If so, how long? No Formula/Milk type? Page 3 of 8
4 Has your child reached all age-appropriate milestones? (e.g. crawling, walking, talking, teething?) Yes No When was the last time your child had a fever? What was the cause and temperature reading? Has your child ever had exposure to lead, pesticides, mercury, chemicals, etc. Yes No (If yes, please list below) FAMILY HISTORY Please list all the diseases and indicate familial relation (parents, grandparents and siblings only) MOTHER S HEALTH DURING PREGNANCY Bleeding Y N Nausea Y N Hypertension Y N Diabetes Y N Physical or emotional trauma Y N Thyroid problems Y N Illnesses Medications Cigarettes, alcohol, drug consumption Y N (If yes please specify: ) Y N (If yes please specify: ) Y N (If yes please specify: ) Mother s age at birth? DIET Does your child follow a specific diet? Y N (Check all that apply) Vegetarian Vegan Paleolithic Anti inflammatory Blood type Low-fat/low calorie Gluten-free Dairy-free Other: Page 4 of 8
5 Please describe your child s diet as accurately as possible. Breakfast Lunch Dinner Snacks Beverages List certain foods that your child does not eat? How is your child s appetite? Does he or she skip meals regularly or need multiple snacks between meals? Yes No Are there certain foods that your child craves more than others? Yes No (If yes, please list below) What nutritional goals do you have for your child? PHYSICAL ACTIVITY Please explain your child s usual energy level? At what part of the day is his/her energy level the highest? At what part of the day is his/her energy level the lowest? Page 5 of 8
6 What does your child do for physical activity/how often do they do this? Does your child participate in any sports? Yes No (If yes, please list below) MENTAL/EMOTIONAL Does your child seem more emotional than their siblings and/or other children? Yes No (If yes, please describe below) Does your child play with other children? Yes No Does he or she join groups easily or prefer to play on their own? Yes No Does your child show a lack of interest in participating in activities or doing everyday things? Yes No (If Yes, how often?) Does your child have any significant fears? Yes No (If yes, please list below) Does your child have night terrors? Yes No (If yes, please describe below) Does your child have difficulty with sleep? Yes No (If yes, please describe below) Does your child wet the bed? Yes No (If yes, please describe how often below) Page 6 of 8
7 LIFESTYLE What types of daily or weekly lifestyle habits/activities do you feel support or strengthen your child s health? What obstacles or challenges do you potentially anticipate may undermine your child s health and/or follow through with recommendations? What do you know will support you and your child consistently with the lifestyle changes your child will be making to regain their health and vitality What does your child love doing? What brings them joy? Page 7 of 8
8 REVIEW OF SYMPTOMS (Please check all that apply) Hives Burning urine Bloody urine Eczema Hair loss Cries easily Bleeding gums Heart murmur Nervous/anxiety Dizzy spells Nose bleeds Vomiting spells Sleep problems Asthma Polyuria Acne Anemia Night sweats High fevers Allergies Jaundice Sensitive to light Chronic rash Stomach aches Sadness Diarrhea Hearing loss Easy bruising Sore throats Cough Flat feet No appetite Body/breath odor Constipation Nightmares Frequent colds Bleeding tendency Unusual fears Wheezing Joint pain Excessive fatigue Behavior issues Difficulty learning Other: _ Page 8 of 8
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