Date of Birth: Age: Sex: male female. Weight: Height: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s

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Transcription:

*All information provided is kept in strict confidence Child s Name: Date: Date of Birth: Age: Sex: male female Weight: Height: Girls: Age at first period: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s E-mail: Father s Phone: (home) (cell) (work) Father s E-mail: Emergency contact: (name) (relationship) telephone: (home) (cell) Primary care physician: (name) (telephone) Address: Referred by: P. 1 of 7

Main concerns, in the order of priority, and date started: Can you trace the origin of any present condition to any particular circumstance? (e.g. accident, illness, grief, mental upset, etc.) Prescription medications, non-prescription medications and health supplements the child is currently taking: Name Dosage Condition treated Since when Other treatments or therapies: Name Frequency Since when Substances the child is using: Description Amount Description Amount Alcohol Chewing Tobacco Cigarettes Coffee Laxatives / Purgatives Pain Killers Recreational Drugs Sleeping Pills Tea Other Allergies: P. 2 of 7

Medical history Medical procedures, surgeries, hospitalizations, accidents and major trauma Date Description Vaccinations: Measles Mumps Rubella Pertussis Chicken Pox Flu Other Adverse reactions: Which of the following has the child experienced or is suffering from now: Abortion Colic Goitre Leukaemia Parasites Tonsillitis Alcoholism Constipation Hard to please Malaria Pneumonia Tuberculosis Allergies Convulsions Hay Fever Measles Rheumatic Fever Undescended testicles Anemia Depression Heart Murmur Mental problems Sexual Abuse Urticaria Appendicitis Diabetes Hepatitis Miscarriage Skin Disease Vision Asthma Diarrhea Herpes Mononucleosis Sinusitis Warts Bedwetting Breathing Digestive Hypertension Much crying Sleeping Ear Infections Influenza Mumps Speech Worms Whooping Cough Burns Eczema Injuries Nervousness Strep Throat Yellow Fever Cancer Epilepsy Jaundice Night Terrors Tantrums Other Chicken Pox Frequent Colds Kidney Disease No energy Teeth Cold Sores Gall Stones Learning Nosebleeds Thyroid problems P. 3 of 7

Child s Birth History Birth Weight: Rh Blood? Any complications during and/or after delivery? Number of hours in labour: Was the delivery: Normal Premature Caesarean Forceps aided At home In hospital Drug aided Difficult Was the child breastfed? If yes, for how long? Type of formula used? At what age was: milk introduced? solid foods? What foods were first introduced? Mother s Pregnancy History Did you have any problems conceiving? Did you have a stressful pregnancy? Did you experience any of the following? Anaemia Fatigue Nausea Vomiting Did you use any of the following during pregnancy? Alcohol Antibiotics Cigarettes Iron supplements Recreational drugs Sedatives Sleeping pills Other Did you undergo x-rays? Ultrasound? How much weight did you gain during pregnancy? Did you have any food cravings or aversions during pregnancy? If yes, what were they? During the pregnancy, did you suffer any shocks, traumas, or losses? If yes, explain P. 4 of 7

Family history: Ailments which may be present in your family history: Alzheimer s Diabetes Hypertension Mental problems Tuberculosis Alcoholism Depression Heart Disease Skin Disease Cancer Gonorrhoea Hepatitis Syphilis Relationship Age Diseases Age at death Mother Father Cause of death Brother(s) Sister(s) Children Maternal Grandmother Grandfather Aunts Uncles Paternal Grandmother Grandfather Aunts Uncles P. 5 of 7

Details about your Child s symptoms: What triggers the symptoms (mental, emotional and physical symptoms)? Does anything make the symptoms unique? What makes the symptoms better (i.e. hot/cold, eating, sleep, time of day)? What makes the symptoms worse? Is the child affected by the weather? How? Perspiration (odour, night sweats, profuse)? Body temperature: Sleep (falling asleep, waking, position): Average energy level during the day (0 = none, 10 = max.): Has the child lost any weight recently? How much? Is there anything else regarding the child s overall condition that we should know? P. 6 of 7

Do you give permission to share your child s information with other health care providers for purposes of medical evaluation? yes no (signature of parent or guardian) How did you hear about K-W Homeopathic Medicine and Wellness Clinic? Referral from Health Care Practitioner Internet Referral from family or friends Newspaper Public Health Talk Magazine St. Jacobs Farmers Market Event Other Thank you for taking the time to fill out this form! P. 7 of 7

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