Pediatric intake questionnaire2.xlsx

Keweenaw Holistic Family Medicine Pediatric Intake Form Parents marital status (circle): Married / Separated / Living Together / Other:Current Grade in School: Please indicate the severity of your symptoms by checking the box that applies to each symptom (sx).
Part I: ENT - Allergy Symptoms
Mild Moderate Severe
Moderate Severe
No Sx Mild Sx
No Sx Mild Sx
Severe Sx
Nose Symptoms
Chest Symptoms
Nervous System
Skin Symptoms
Throat Symptoms
Urinary System
Ear Symptoms
Eye symptoms
Keweenaw Holistic Family Medicine Pediatric Intake Form Part I: ENT - Allergy Symptoms, Continued
Has Pt taken antibiotics for acne for 1 month or Includes: tetracycline (Doxycycline, Minocin) and Has Pt taken "broad spectrum" antibiotics for infections (respiratory, urinary, or other) for 2 months Includes: Keflex, Ampicillin, Amoxicillin, Ceclor, Bactrim, Septra, Ceftin, Cefzil, cipro, Levaquin, Avelox, Tequin, Zithromax, Ketek and more Has Pt ever taken a "broad spectrum" antibiotic, even Includes most intravenous (IV) antibiotics Has Pt used oral or injected steroid drugs (Cortisone, Prednisone, Medrol, Decadron) even one time? Keweenaw Holistic Family Medicine Pediatric Intake Form Moderate Severe
Moderate Severe
No Sx Mild Sx Moderate Sx
Symptoms, "Major"
Symptoms "Minor"
Symptoms "Minor" Cont.
List any foods child dislikes or foods that disagree with child: Keweenaw Holistic Family Medicine Pediatric Intake Form Yes / No What kind? _______________________________ Yes / No Hours/Night? _____________________________ How many hours of sleep per night does child get? …Fall asleep easily (w/in 5 min)?… Wake to urinate?… Wake at other time(s)?… Snore? On a scale of 1-10, with 10 being the most energy and most stressful, where would you rate your child's: Birth History
Among the children in the family, child ranks: (circle) Oldest / Middle / What was mother's state of mind during child's Mother's health during child's pregnancy: (circle all that apply) Healthy - pregnancy? (circle all that apply) Happy / Angry / Diabetes - Hypertension - Smoking - Caffeine - Alcohol - Nausea/Vomiting - Alcohol - Recreational Drugs - Emotional Stress Were child's developmental milestones (talking, walking): How was mother's relationship with father during child's pregnancy? Good / Strained / Bad / None at all Vaginal or Cesarian birth (circle). Number of weeks at delivery: Labor was Spontaneous or Induced (circle). If induced, please explain:Labor was in a hospital or other (circle). If other, please describe:Number of hours of labor: Pre-School Age
School Age: Elementary
When Pt started going to school, how did he/she like it? During Pt's pre-school years, how did Pt's parents relate to each other? As a small child, did Pt need medical When Pt remembers pre-school years, does treatment for: Keweenaw Holistic Family Medicine Pediatric Intake Form School Age: Elem, continued…
Did Pt have any injuries or operations while Is Pt "hyperactive" or been given drugs for Did Pt's behavior or relations with teachers and friends suffer in Middle school? (circle) Did Pt's grades change in Middle/ Jr. High school? (circle) While in high school, did Pt have problems with: (circle) Relations with classmates / Run-ins with the Law / Alcohol or drug use / Health problems / Operation or injury During Pt's childhood and through high school, has Pt been bereaved Activity and exercise during school years: (check a box with your estimate) During any time in Pt's childhood or teen years, has Pt suffered from Has Pt suffered from other stressful events at any time in their life that have not been covered here? You may use this space to note them. Go to the back side of this paper if you need to write more. Thank you! Any problems with menstrual cycle? (cramps, pain, heavy flow, mood swings, etc) Please list.
Any difficulty tolerating Has Pt's cycles or the pattern of her menstrual flow changed Keweenaw Holistic Family Medicine Pediatric Intake Form When you have completed this long, long questionnaire, I will have a pretty good idea about your/your child's health problems. Yet, I need your help in setting our goals.
Your top three health goals. If, given the opportunity to cure/fix your health problems… What are your three biggest health problems to be wished away? Please be clear and specific.
One last question: How many doctors have you seen about these problems? ___________________ This completes the packet of questions we will review at your first visit to the office. Please use the space below or on the back of this page to note questions and comments that you wish to discuss at your visit with me.
Thank you for your hard work and all the time you spent completing this!



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