II. Goal and Expectations (Please tell us your goals and expectations.) III. Childhood Illnesses (Please check those illnesses that you have had.

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1 Natural Health and Wellness Center The path to a healthier, more vital you. PEDIATRIC HEALTH HISTORY QUESTIONNAIRE SUCCESSFUL HEALTH CARE AND PREVENTION ARE ONLY POSSIBLE WHEN THE PROVIDER HAS A COMPLETE UNDERSTANDING OF THE PATIENT PHYSICALLY, MENTALLY AND EMOTIONALLY. PLEASE COMPLETE THIS QUESTIONNAIRE AS THOROUGHLY AS POSSIBLE. PRINT ALL INFORMATION AND MARK ANYTHING YOU DON'T UNDERSTAND WITH A QUESTION MARK. PATIENT: DATE: I. Summary of Current Conditions What are the most important health concerns for your child? Please list as many as you can in the order of importance. Please include the date when the condition began. This condition interferes with: School Sleep Exercise Other This condition is: Getting worse Getting better Staying the same What do you believe is the cause? How is the condition being treated? Do you have any known contagious diseases at this time? Yes / No II. Goal and Expectations (Please tell us your goals and expectations.) If yes, what disease? III. Childhood Illnesses (Please check those illnesses that you have had.) Scarlet Fever Diptheria Rheumatic Fever Mumps Measles German Measles IV. Immunizations Measles/Mumps/Rubella(MMR) Varicella Zoster(Chicken Pox) Diptheria/Pertussis/Tetanus (DPT) Polio Influenza Date of last Tetanus: Hepatitis B Date of last Flu Shot: Other: Any reactions to vaccinations? If so, please explain:

2 V. Hospitalizations and Surgeries (What hospitalizations or surgeries have you had?) Year: Year: Year: Year: VI. X-rays and Special Studies (X-rays, CT scans, or other studies you have had.) Year: Year: Year: Year: VII. Allergies (Are you hypersensitive or allergic to any of the following?) Medications: Reaction: Foods: Reaction: Environmentals: Reaction: VIII. Family History Age (if living) Health (G=good; P=poor) Age at death (if deceased) Mark (X) those applicable Diabetes Heart Disease High Blood Pressure Stroke Epilepsy Thyroid Disease Mental Illness Asthma/Hayfever/Hives Allergies Anemia Kidney Disease Glaucoma Tuberculosis Migraines Cancer Others Father Mother Brothers Sisters Grandparents Cause of Death

3 IX. Medications (Please list all medications from drugstore or prescription.) Medication: Dosage: Medication: Dosage: X. Supplements, Vitamins, Herbs Brand/Store: Supplement: Dosage: Brand/Store: Supplement: Dosage: XI. Health History of Child Child Breastfed: Yes No For how long: When put on formula: What formula was used: When was child put on solid food: When did child walk: Talk: Develop Teeth: Any particular household stressors child has witnessed or gone through: 1) 2) 3) 4) Jaundice as baby: Yes No Cradle Cap: Yes No Eczema or Psoriasis: Yes No Diarrhea: Yes No Constipation: Yes No Finicky Eating: Yes No Poor Teeth: Yes No Chronic Sniffles/Stuffy Nose: Yes No Bad Foot Odor: Yes No Very Sweaty Baby/Child: Yes No Hyperactivity: Yes No Growing Pains: Yes No Diabetes: Yes No Ear Infections: Yes No Fatigue: Yes No Headaches: Yes No Hyperactivity: Yes No Thyroid Problems: Yes No Weight Gain/Loss: Yes No Colic: Yes No Anemia: Yes No Asthma: Yes No Cough/Wheeze: Yes No Warts: Yes No Nightmares: Yes No Bed-wetting: Yes No Tantrums: Yes No Disobedient: Yes No Fears/Phobia: Yes No Diaper Rash: Yes No Early Puberty: Yes No Stomach Aches: Yes No Vomiting Spells: Yes No Epilepsy/Seizures: Yes No Frequent Infections: Yes No Heart Murmur: Yes No Learning Disorder: Yes No Other:

4 XII. Mother s Pregnancy History/Health During Pregnancy Age at conception: Did she have any other children already? Yes No Smoking: Yes No Gestational Diabetes: Yes No Coffee: Yes No Nausea/Vomiting: Yes No Recreational Drugs: Yes No Preeclampsia: Yes No Length of labor: Vaginal Birth: Yes No Cesarian Delivery: Yes No Traumatic Birth Yes No If the birth was difficult, please explain: Health of baby at birth: XIII. General Review/Dietary Habits Weight: Weight 1 year ago: Height: Does child sleep well? Yes No How many hours of sleep per night: Naps? Does child watch television? Yes, hrs/day: No Do child spend time outside? Yes No Are parents (please circle one): Married Separated Divorced Other: Mother s Occupation: Fulltime / Partime Father s Occupation: Fulltime / Partime Other s residing in home? Yes No Daycare? Yes No Please describe child s dietary habits: Breakfast: If yes, where? Relationship: Lunch: Dinner: Snacks: Does child have food allergies/intolerances? Yes No Please describe: Does child experience food cravings? Yes No For what types of food? How many glasses of water/day does child drink? Is it filtered water? Yes No How much soda or juice/day does child drink? Diet: Yes No What type:

5 Is there anything else you would like the doctor to know about you/your child? XV. Toxic Exposure History Did child ever live near a refinery, polluted area or in a house with lead paint? Please explain: Has the child ever lived in a house that had new carpeting/cabinets, paint, cabinets or any other refurbishing that seemed to affect their health at all? Please explain: Does the child seem particularly sensitive to perfumes, cleaners, gasoline or other vapors? Please explain: Do you use herbicides, pesticides, or other chemicals around your home? Please explain: XVI. Complementary Care History Please indicate each type of complementary care that you have tried or that interests you. Please list others if not listed. Acupuncture: Lifestyle Counseling/ Stress Management: Spiritual Direction: Chiropractic: Hypnotherapy: Reiki: Homeopathy: Hydrotherapy: Yoga: Naturopathic Medicine: Mind-Body Medicine Chinese Herbs: Nutritional Counseling: Meditation: Western Herbs: Massage Therapy: Guided Imagery: Environmental Medicine: Other: Other: Other: