PEDIATRIC REGISTRATION FORM
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1 MONTCLAIR HOMEOPATHY LLC Linda Corenthal Robins, M.D. Montclair, NJ 0704 Office PEDIATRIC REGISTRATION FORM Referred by: Name Nickname Birth date Mother s Name and Address: Father s Name and Address: Home #: Work #: Home #: Work #: Occupation: Occupation: Members of Household: Name Age Relationship Name of school or day care Place of birth: Home Hospital Birth weight: Drug allergies or reactions to medications:
2 Check the relevant box if the child s mother had any of these problems during her pregnancy with this child: High blood pressure Diabetes or sugar in urine Was this child born premature? Albumin or protein in urine Was the birth difficult? Urinary infection Was the baby born with forceps, German Measles (3-day) cesarean, breech? (circle) Gonorrhea or Syphilis Did the baby need help to start Drug or drinking dependence breathing or other problems? Frequent cigarettes Other problems or treatment or illness: explain Did the baby remain in the hospital longer than the mother? Was this baby breastfed? To what age? Has this child ever had the following problems: Asthma Blood disorders (anemia, etc.) Chicken pox Convulsions or fits Croup Pneumonia Frequent bronchitis German measles (3-day) Hospitalization or operations Mumps Eczema Scarlet fever Rheumatic fever Worms Whooping cough Please check the immunizations this child has had: DPT (diphtheria, pertussis, tetanus) Small Pox Mumps Polio Measles HIB Tetanus Other Rubella Hepatitis 2
3 If your child has ever been bothered with any of the following problems check the box Frequent headaches Bedwetting (> 4 years old) Eye irritation Daytime wetting (> 3 years old) Eyes crossing Discharge from penis or vagina Trouble with vision Marked increase/ decrease in Wears glasses appetite Earaches or runny ears Weight loss or gain Difficulty hearing Rashes or swellings after eating Pulling or tugging of ears certain foods Speech impediment Hay fever or allergies in spring, Dental problems to animals, etc. Sore or bleeding mouth or gums Skin rashes or swellings Bruises or bleeding problems Itching skin Frequent colds Warts Mouth breathing Accidental poisoning Recurring nosebleeds Listless or tired Recent sore throat Recurrent fevers Hoarse voice Motion sickness Wheezing or gasping Serious accidents, sprains, Coughing spells broken bones Shortness of breath while Shyness walking or playing Frequent nightmares Must squat or hunch down often Waking often during night while playing Fears Chest pains Overly clinging Burping or gas Easily upset, crying Abdominal pain Temper fits Vomiting Breaks or throws things Diarrhea Fighting Constipation Stealing Itching at anus Lying Blood with stools Nervous or nervous habits Must have a special diet Special school or classes Frequent urination at school Pain or crying when urinating with the family Brown black or bloody urine 3
4 Place an (x) in the appropriate columns for any illnesses that this child s blood relatives have had Allergies Anemia Arthritis/ Gout Asthma Bleeding/ Bruising Cancer or Tumors Convulsios Epilepsy Diabetes Drinking or Drug Eczema Emphysema Heart Trouble Hepatitis High Blood Pressure Frequent Infections Father Mother Brother/Sister Grandparents: Maternal Paternal 4
5 Kidney/ Bladder Mental Illness Migraines Abnormal Periods Psoriasis Pneumonia Polio Prostrate Rheumatic Fever Stomach or Intestinal Disease Stroke Thyroid Tuberculosis Ulcers Venereal Disease Weight Problem Father Mother Brother/ Sisters: Grandparents Maternal Paternal CONSENT FOR TREATMENT FINANCIAL AGREEMENT: By signing this document, I hereby authorize Dr Corenthal Robins to treat my child using homeopathic medicines according to the principles of homeopathic practice. I understand and acknowledge Dr Corenthal Robins will base her treatment decisions on the school of homeopathic practice and that if I desire my child to be treated according to the traditional or allopathic school of medicine, I am free to seek such treatment form another physician, In some cases, it may be encouraged or required to do so. I understand Dr Corenthal Robins will make the best effort to treat my child, but makes no guarantees that her homeopathic treatment will cure my child. I also authorize Dr Corenthal Robins to video tape the interviews for the use of inter staff consultation on my child s case and /or for the use of teaching students of homeopathy. I certify that the above information is true and give Dr Corenthal Robins permission to contact previous physicians. I understand that appropriate charges will be made and hereby agree that I am financially responsible for any such charges. Signature of Parent/Guardian Date Macintosh HD:Desktop Folder:Linda's:MONTCLAIR HOMEOPATHY:PEDIATRIC REGIST FORM
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Dr. Jeannie Doig, HBSc, ND Naturopathic Physician Port Alberni (250)
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