Pediatric Health History Questionnaire Marlborough Wellness Center

Pediatric Intake

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*
Month
Day
Year
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
- Fevers
- Sweat Easily
- Bleed or Bruise Easily
- Change in Appetite
- Sudden Energy Drop
- Poor Sleeping/Insomnia
- Chills
- Weight Loss/Gain
- Strong Thirst
- Fatigue
- Night Sweats
- Cravings
If sudden energy drop, What time of day?
If Cravings, for what?
Skin and Hair
- Rashes
- Itching
- Change in Hair/Skin Texture
- Ulcerations
- Eczema
- Hives
- Loss of Hair
- Acne
- Recent Moles
- Other
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
- Dizziness
- Glasses
- Poor/Blurry Vision
- Cataracts
- Eye Strain
- Eye Pain
- Eye Surgeries
- Color Blindness
- Floaters (Spots in Front of the Eyes)
- Night Blindness
- Tinnitus (Ringing in the Ears)
- Earaches
- Poor Hearing/Hearing Aids
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
- High Blood Pressure
- Low Blood Pressure
- Irregular Heartbeat
- Cold Hands/Feet
- History of Blood Clots
- Difficulty Breathing
- Swelling of Hands/Feet
- Phlebitis
- Chest Pain
- Fainting
- Other
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
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Gas
- Belching
- Black Stools
- Blood in Stools
- Indigestion/"Tummy aches"
- Bad Breath
- Rectal Pain
- Hemorrhoids
- Bleeding Gums
- Abdominal Pain/Cramps
- Other
If Other, describe:
Food Avoidance: Are there any food avoidance issues? Does the child experience any side effects after eating certain foods?
Genitourinary
- Pain Upon Urination
- Frequent Urination
- Blood in Urine
- Urgency to Urinate
- Unable to Hold Urine
- Night Urination
- Kidney Stones
- Decrease in Flow
- Sores on Genitals
- Other
If Other, describe:
If Night Urination, how frequently and when did it start?
Musculoskeletal
Please check areas where the child experiences pain
- Neck
- Back/Spine
- Hand/Wrist
- Shoulder
- Elbow
- Knee
- Ankle
- Hips
- Muscle Weakness
- Numbness
- Parathesias (Tingling)
- Other
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.
- Seizures
- Dizziness
- Loss of Balance
- Lack of Coordination
- Poor Memory
- Concussion
- Depression
- Anxiety
- Bad Temper
- Easily Susceptible to Stress
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.

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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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