Head to Heal Family Wellness Centre for Naturopathic Medicine & The Bowen Technique CHILDREN S QUESTIONNAIRE (To be completed by parent/guardian) Date: Child s Name: Mother s/guardian s Name: Mother s/guardian s Occupation: Address: Work Phone Number: Father s Name: Father s Occupation: Work Phone Number: Home Phone Number: Child s Birth date: Child s Age: How did you hear of Head to Heal? Name of your child s pediatrician/doctor: Does this child see any other health care providers? No Yes If yes please provide details Please state your child s primary reason for attending this clinic. Please list the first time you noticed the condition and describe any factors that you suspect may have a role in its onset and perpetuation: Please list any other health concerns/complaints: PAST MEDICAL HISTORY: Childhood Illnesses (please check and indicate child s age at time of infection) o Measles o Rheumatic fever o Mononucleosis o Rubella o Scarlett fever o Strep throat o Mumps o Polio o Conjunctivitis o Whooping Cough o Tonsillitis o Other o Chicken Pox o Frequent colds o Pneumonia o Ear infections (how many? )
VACCINATION RECEIVED: (please check or attach a photocopy of vaccination record): Please note any adverse reaction to vaccinations (For example: redness at site, crying, screaming, fever, limp etc.) FAMILY HISTORY: (please indicate where applicable) Was this child adopted? No Yes, If yes please indicate date: Type of vaccination Date received? Type of vaccination o Diptheria, Pertussis, Tetanus o Measles, Mumps, Rubella o Polio o Chicken pox o Haemophilus Influenza B o Prevnar o Influenza o Other Age (if living) Health (G=good, P=poor) Allergies Anemia Asthma, Hayfever, Hives Cancer Cystic Fibrosis Diabetes Epilespy Rheumatoid Arthritis Heart Disease High Blood Pressure Kidney Disease Mental Illness Alcoholism Date received? Father Mother Brothers Sisters Grandmother Grandfather Maternal Paternal Maternal Paternal
List all family members the child lives with: PRENATAL HISTORY: Parents health at conception (G= good, P= poor): Mother Was the child conceived naturally? Yes No Any fertility interventions? Yes No Any illness of difficulties during pregnancy for mother? (please circle) Father: List all drugs, alcohol, cigarette smoking or medications taken during pregnancy: List any vitamins or other supplements taken during pregnancy: Mother s age at birth: Father s age at conception: Mother s pregnancy weight gain lbs BIRTH HISTORY: How long was the pregnancy? (please circle) Full Term Late Premature # of weeks Was the labour spontaneous or induced? (please circle one) Duration of labour?: hrs Difficulties or complications: Was the delivery by C-section or vaginal birth? (please circle one) Hospital or Home Birth (please circle one) Stroke Tuberculosis Other Age (at death) Cause of death Nausea Diabetes Hypertension Thyroid problems Bleeding Illness Physical trauma Emotional Trauma Vomiting Any other: Child s Birth Weight? Child s Birth length: APGAR scores: 1 min 5 min
Interventions: (please circle) Epidural Episiotomy Forceps Suction Complications: NEONATAL HISTORY: Any difficulties or complications soon after birth? (please check where applicable) o Rashes o Other Age began: Sitting Crawling Walking Talking 1 st tooth Any problems with the child s teeth? How would you characterize your child s development? (circle) Has child started puberty? No NUTRITION: Infant feeding: o Jaundice o Poor feeding o Respiratory distress o Anemia o Convulsions o Infections o Birth defects o Colic Physical: Slow Average Fast Mental: Slow Average Fast Yes, If yes when? Breast fed how long? Formula fed describe type: When started: Age of introduction of solids: What were the first foods introduced? Childhood eating habits: Are there any foods groups excluded from your child s diet? Why? GENERAL QUESTIONS: Has your child ever experienced any trauma? (please circle) Fractures: No Yes Accidents: No Yes Emotional: No Yes Please describe if you answered yes to any trauma:
Has your child ever been hospitalized? No Yes If yes please describe why and what year Is your child taking any medications or supplements? No Yes If yes, please list what and quantity: How many times has your child taken antibiotics? Do you live close to any of the following? (please circle) Industry Power lines Highway Dump Airport How would you describe your child s daycare or school experience (if appropriate) in terms of performance, enjoyment and socialization? Has your child had any specialized screening tests? Please explain. What are your child s interests? How many days/week does your child participate in out-of-school programs? Would you characterize your home environment as (please circle): Very stable Stable Stressful Very stressful How many hours per day does your child use: TV Computer Video games Have you done any major renovations to your home recently? How old is your home? How long have you lived there? Are there any pets in your household? Is the child exposed to tobacco smoke? Does your child have any drug allergies? Please describe Does your child have any food allergies? Please describe Has your child ever traveled outside of Canada? Where and when?
GENERAL SYMPTOMS: (please check current symptoms, uses a P to indicate for past) Acne Slow wound healing Eczema, rashes Hives, itching Changes in skin odour Changes in hair/nails Cradle cap Recent weight change Weakness, fatigue Muscle or joint pain/stiffness Change in posture/gait Trouble chewing/swallowing Change in appetite Excessive/diminished thirst Excessive/diminished hunger Diarrhea Constipation Frequent vomiting Stomach/abdominal aches Excessive belching Excessive gas Sore throat Coughing Lumps, swollen glands Discharge (eyes, ears, nose, other) High fevers Anemia Vision problems Hearing problems Heat and/or cold intolerance Excessive sweating Night sweats Cries easily, weepy Nervous Irritable Sudden change in mood Strong fears or aversions Nightmares, night terrors Memory problems Wheezing, difficulty breathing # of bowel movements/day Body/breath odour Burning urination Bed wetting Frequent urination Motion sickness Joint pain Easy bruising Blood in urine Age at potty training Nose bleeds Is child fully potty trained?
SLEEP: Sleep patterns during first year? Usual time child goes to bed and awakens: Any napping during the day? No Yes, if yes please detail: Difficulties in falling asleep and staying awake? SENSITIVITIES: Is your child particularly sensitive to any of the following? (please circle) Claustrophobia Drafts Heat Smells Wool Briefly describe your child s personality including both positive and negative characteristics: Is there anything else you would like to add that you feel may be relevant to your child s case? Thank you for completing this form as accurately and completely as possible. It will greatly help the doctor to obtain a more complete understanding of your child. Cold Heights Music Sunlight Wind INFORMED CONSENT I, parent/guardian of consent to treatment given to my child by Dr. Vanessa DiCicco ND/Dr. Jonathan Bablad ND. Signature: Date: