Pediatric Health History Questionnaire Pediatric Health History Questionnaire 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 ContactsEmergency Contact's Full Name* Emergency Contact's Phone*All About the ChildDate 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 HistoryNext to each illness/condition that the child has experienced, enter details and specific datesCancer Diabetes Hepatitis High Blood Pressure Heart Disease Rheumatic Fever/Childhood Diseases Thyroid Disease Venereal Disease Other... SurgeriesSignificant Trauma (Auto Accidents, Falls, Abuse, etc.)Allergies (Drugs, Metal/Chemicals, Foods)Medicines Taken in the Last Three Months (Vitamins, Drugs, Herbs)Personal InformationHas the child ever been on a restricted diet? If Yes, what kind and why?Child's Average Daily Diet - Please describe in detailMorningAfternoonEveningIs 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 monthsGeneral 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 receivedIf 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 experiencesIf 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 experiencesIf 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? MusculoskeletalPlease 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: NeuropsychologicalCheck 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 pregnanciesEnter number of live birthsEnter number of miscarriagesEnter number of abortionsEnter number of premature birthsDate of last PAP? Age at first mensesDuration of menses EmailThis field is for validation purposes and should be left unchanged.
