Pediatric Health History Questionnaire Marlborough Wellness Center

Your FULL name*

Your Email*

Child's LAST Name*

Child's FIRST Name*

Street Address*

City/Town*

State*

Zip Code*

Home Phone*

Day Phone*

How did you hear about MWC?

Child's Medical Contacts

Emergency Contact's Full Name*

Emergency Contact's Phone*

All About the Child

Date of Birth*

MM

DD

YYYY

Chronoligical Age (Years or Months)*

Enter an integer representing the number of years or months of the child's age.

Has the child been treated by Acupunture or Oriental Medicine before?*

No
Yes

Main concern(s) you would like us to address*

When did this begin?

How does it interfere with the child's daily activities (ie: school/work, sleep, play)?

Has the child been given a medical diagnosis for this problem?

No
Yes

What other treatments have been tried?

Family Medical History

Diabetes
Cancer
High Blood Pressure
Heart Disease
Stroke
Seizures
Asthma
Allergies
Other

Check all that apply.

if Other, describe.

The Child's Past Medical History

Next to each illness/condition that the child has experienced, enter details and specific dates

Cancer

Diabetes

Hepatitis

High Blood Pressure

Heart Disease

Rheumatic Fever/Childhood Diseases

Thyroid Disease

Venereal Disease

Other...

Surgeries

Significant Trauma (Auto Accidents, Falls, Abuse, etc.)

Allergies (Drugs, Metal/Chemicals, Foods)

Medicines Taken in the Last Three Months (Vitamins, Drugs, Herbs)

Personal Information

Has the child ever been on a restricted diet? If Yes, what kind and why?

Child's Average Daily Diet - Please describe in detail

Morning

Afternoon

Evening

Is the child currently taking any medications? If Yes, describe what and why?

How much water/juice/milk does the child drink per day?

Are there any other concerns you would like us to address?

In all the areas listed below, please check if the child has experienced any symptoms in the past 3 months

General

If sudden energy drop, What time of day?

If Cravings, for what?

Skin and Hair

If Other, please explain.

Immunizations: List all immunizations the child has received and when they were received

If the child has had any childhood diseases like Chickenpox, please list all and describe.

Head/Eyes/Ears/Nose/Throat

Check all that the child experiences

If Eye Surgeries, What and When?

Ear Infections: If the child has a history of ear infections, how many infections and what has been done to address the problem?

Headaches & Migraines: If the child experiences these, where are they located?

More Head/Eyes/Ears/Nose/Throat

Sinus Problems
Teeth Grinding
Nose Bleeds
Jaw Clicks
Recurrent Sore Throats
Sores on Lips/Tongue
Other

Check all that the child experiences

If Other, describe.

If the child has a tendency to catch colds/flus regularly, how frequently per year?

Cardiovascular

If Other, describe.

Respiratory

Cough
Bronchitis
Difficulty Breathing when Lying Down
Asthma
Production of Phlegm
Coughing Blood
Pneumonia
Pain with Deep Breath
Other

If Phlegm, what color?

If Other, describe

Gastrointestinal

If Other, describe:

Food Avoidance: Are there any food avoidance issues? Does the child experience any side effects after eating certain foods?

Genitourinary

If Other, describe:

If Night Urination, how frequently and when did it start?

Musculoskeletal

Please check areas where the child experiences pain

Check the body parts where the child feels pain and all the conditions the child experiences.

If Other, describe:

Neuropsychological

Check all that you experience.

Has the child been treated for emotional challenges?

No
Yes

Has the child ever considered or attempted suicide?

No
Yes

Any other neuropsychological issues?

Reproductive - Complete if applicable for the age of the child.

Is the child pregnant?

No
Yes
I don't know

Is it possible that the child could be pregnant?

No
Yes

Enter number of pregnancies

Enter number of live births

Enter number of miscarriages

Enter number of abortions

Enter number of premature births

Date of last PAP?

Age at first menses

Duration of menses

Name

This field is for validation purposes and should be left unchanged.

Marlborough Wellness Center

Pediatric Health History Questionnaire

Pediatric Intake

Child's Medical Contacts

All About the Child

The Child's Past Medical History

Personal Information

Child's Average Daily Diet - Please describe in detail

In all the areas listed below, please check if the child has experienced any symptoms in the past 3 months

Musculoskeletal

Neuropsychological

Reproductive - Complete if applicable for the age of the child.

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