Clymer Healing Center Woodlands Healing Research Center

5916 Clymer Rd., Quakertown, PA 18951 * 215-536-8001 * Fax 215-536-9099

5724 Clymer Rd., Quakertown, PA 18951 * 215-536-1890 * Fax 215-529-9034

 

CHILD HEALTH HISTORY QUESTIONNAIRE

(Ages: New Born to 12)

Click here to Return to New Patient Information Page

Name of Child:    Date Form Completed:

Gender: Female Male   Date of Birth:      Age:

Attention, Parents or Guardians: As age permits, please have your child participate as much as possible in completing this form. Complete those parts that apply to your child as age allows. Omit the sections that do not apply to you or your child.

This form was completed by (check all that apply):Mother   Father   Child   Other:

MEDICATION ALLERGY AND INTOLERANCE: List any medication or supplement you are allergic to or which caused unpleasant side effects; include the name of the substance, the age it occurred, how it was taken (mouth, vein, etc), what reaction occurred, and the treatment if given. Use additional sheets if necessary.       

Prescription Medication Date Route given Reaction Any Treatment Given
Example: Penicillin    02/2002 By mouth Hives, breathing difficulty None

MEDICATIONS: List medicines, both prescribed by a physician and obtained without a prescription (those that you can buy on your own), that you are currently taking or have taken recently. Complete as much as you are able. Including the name of the medicine, the strength of the medicine (dosage), how often you take it (frequency), date started and date stopped if you are no longer are using it. Please bring all your medication to your appointment. Use the other side of this sheet or additional sheets if necessary.

Medication Dose Frequency (times per day) Started Stopped
Example: Benadryl 25mg 1 pill 2 times per day 1990 ---------

VITAMINS, MINERALS, AND OTHER NUTRITIONAL SUPPLEMENTS:

As above, please list your nutritional supplements to include vitamins, minerals, herbs, homeopathic remedies, folk remedies, and other nutritional or alternative therapies. Please include the form of the supplement (pill/liquid, etc), and the dosage (mg, IU, etc). Please bring all your supplements to your appointment. Use the other side of this sheet or additional sheets if necessary.

Vitamin/Herb/Supplement Dose Frequency (times per day) Started Stopped

Antibiotics: List the number of times you have been on antibiotics such as Penicillin, Tetracycline, Amoxicillin, Keflex, Ceclor, Erythromycin, or other antibiotics: NO      YES, The number of times given antibiotics:

Please check any of the reasons listed as to why  you were prescribed antibiotics, include as many as apply:

Acne/skin condition   Colds    Tonsillitis/Strep Throat    Ear Infection(s)     Bladder/Kidney Infection

Other:

Steroids: Have you ever taken an oral cortisone preparation such as Prednisone, Decadron, Medrol, or others? If yes, state how many times.  NO    YES, The number of times given steroid pills:

Have you received a cortisone type "shot" such a Depo Medrol, Decadron, Kenalog, or others?

 NO   YES, The number of times given steroid injections:

CHIEF COMPLAINT: In your own words, what are your main complaints? State the nature and duration of the symptoms:
Severity (of chief complaint): Mild Mild to Moderate Moderate Moderate to Severe Severe
Interferes with my life, how?:
Antecedents: When was the last time you were well? What happened after that time?
During the 12 months preceding the onset of your present condition(s), check those that apply and briefly comment:
Was under severe stress:
Moved to new residence or home:
Traveled outside the U.S.:
Involved in wilderness activity:
Experienced an injury or an acute illness:
Took drugs or medications:
Had chemical or toxic exposure:

 

REVIEW OF SYMPTOMS: Check the symptoms that apply to you. Note whether the symptom is past, now or both:
General:    
Past Now Tired without effort Past Now Fever Past Now Flu like symptoms
Past Now Chills Past Now Night sweat Past Now Cold intolerance
Past Now Heat Intolerance Past Now Weight Gain: lbs Past Now Weight Loss: lbs
Neurological: Past Now Attention Difficulties Past Now Concentration prob's
Past Now Can't Decide easily Past Now Thinking Difficulties Past Now Poor memory (long term)
Past Now Poor Memory (short term) Past Now Disorientation Past Now Hyperactivity
Past Now Constant Movement Past Now Low Activity (Hypo)  
Past Now Sleep too much Past Now Difficulty falling asleep Past Now Frequent awakening
Past Now Nightmares Past Now Restless Legs Past Now Un-refreshed Sleep
Past Now Dizziness Past Now Fainting/Blacking out Past Now Convulsions/Seizure
Past Now Speech problem Past Now Burning sensations Past Now Electrical Zaps
Past Now Numbness Past Now Tingling Past Now Headaches
Past Now Weakness Past Now Clumsiness Past Now Tremors
Past Now Repeats same action(s) Past Now Head Banging Past Now Rocking
Past Now Picking Past Now "Pill rolling" actions Past Now Paralysis
Mental/Emotional:    
Past Now Anxiety/Nerves on edge Past Now Apprehension Past Now Fearful
Past Now Fearful of going out Past Now Other Specific Fear:
Past Now Panic Episodes Past Now Flashback memories:
Past Now Depressed mood Past Now Hopelessness Past Now Guilt
Past Now Lost of interest in play Past Now Suicidal Thoughts Past Now Suicidal Attempt(s)
Past Now Angry Past Now Irritable Past Now Mood Swings
Past Now Jekyll/Hyde personality Past Now Stress @ work Past Now Stress @ home
Past Now Anorexia Past Now Binge eating Past Now Impulsive eating
Past Now Purging Past Now Sugar cravings Past Now Anti-social behaviors
Past Now Compulsive behaviors Past Now Obsessive behaviors Past Now Defiant behavior
Past Now Temper Tantrums Past Now Hallucinations  
Eye: Past Now Vision Change Past Now Blurry Vision
Past Now Spots/floaters Past Now Glasses Past Now Contact lenses
Past Now Pain in eye(s) Past Now Red eye(s) Past Now Dryness
Past Now Light sensitivity Past Now Swelling of eye(s) Past Now Itchy eye(s)
Past Now Cataract(s) Past Now Glaucoma Past Now Infection
Head/Neck: Past Now Head tenderness Past Now Jaw pain
Past Now Neck stiffness Past Now Neck tenderness Past Now Swelling
Past Now Swollen glands Past Now Lump(s)  
Ears: Past Now Recurrent Infections Past Now Drainage/discharge
Past Now Earaches Past Now Hearing Loss Past Now Wears Hearing Aid
Past Now Itching Past Now Noise Sensitivity Past Now Tinnitus
Past Now Vertigo Past Now Redness  
Nose: Past Now Frequent Colds Past Now Congestion
Past Now Runny nose Past Now Post Nasal Drip Past Now Nose blockage
Past Now Itching Past Now Sneezing Past Now Nose Bleeds
Past Now Snoring Past Now Facial Pain Past Now Sinus Pain
Mouth/Throat: Past Now Cracked Lips Past Now Sore Lips
Past Now Dry Mouth Past Now Sores in mouth Past Now Ulcers in mouth
Past Now Bad Breath Past Now Coated Tongue Past Now Abnormal Taste
Past Now Metallic Taste Past Now Gum Problems Past Now Bleeding Gums
Past Now Toothache Past Now Loose/Missing Teeth Past Now Grinding of teeth
Past Now Chewing difficulty Past Now Dentures Past Now Silver (metal) Fillings
Past Now Sore Throats-frequent Past Now Swollen Tonsils Past Now Hoarseness
Respiratory/Lungs: Past Now Short of Breath @ rest Past Now Short of Breath-exertion
Past Now Short of Breath-lying Past Now Wheezing Past Now Cough-occasional
Past Now Cough-all the time Past Now Cough- dry Past Now Cough- phlegm
Past Now Cough with blood    
Cardio-Vascular/Heart: Past Now Chest Pain @ rest Past Now Chest Pain-exertion
Past Now Chest Pressure Past Now Fast Heart Rate Past Now Slow Heart Rate
Past Now Palpitations Past Now Coldness of hands/feet Past Now Blue hands/feet
Past Now Fingertips discolored Past Now Fingertips white Past Now Leg pain when walking
Past Now Swelling feet/legs Past Now Ulcers of feet/legs Past Now Varicose veins
Digestive/Gastro-Intestinal: Past Now Change of Appetite Past Now Eats Dirt/Paint/Plaster
Past Now Ravenous Appetite Past Now Poor Appetite Past Now On a Weight Loss Diet
Past Now Difficulty Chewing Past Now Difficulty Swallowing Past Now Indigestion
Past Now Heartburn Past Now Use Anti-acids Past Now Belching
Past Now Reflux Past Now Nausea Past Now Vomiting
Past Now Vomiting Blood Past Now Vomiting-projectile Past Now Abdominal Lump/Mass
Past Now Abdominal Bloating Past Now Abdominal Distension Past Now Abdominal Pain
Past Now Distress from eating Past Now Hernia Past Now Yellow Jaundice
Past Now Food Intolerances: Please list past and/or present food triggered symptoms (any symptoms).
  Food Symptom(s)   Food Symptom(s)
Past Now Past Now
Past Now Past Now
Past Now Past Now
Past Now Colitis Past Now Gas/Flatus-excessive Past Now Constipation
Past Now Uses Laxatives Past Now Diarrhea Past Now Can't control bowels
Past Now Change in bowel habits Past Now Abnormal Stools Past Now Blood in stools
Past Now Black/Tar-like stools Past Now Undigested food in stool Past Now Rectal Fissue
Past Now Rectal Fistula Past Now Hemorrhoids Past Now Rectal Pain
Past Now Rectal Itching    
Urinary: Past Now Bed Wetting Past Now Bladder Pain
Past Now Recurrent Ur Infections Past Now Urine Dribbling Past Now Painful Urination
Past Now Urine Urgency Past Now Urine Frequency Past Now Wake Up to Urinate
Past Now Slow Stream Past Now Loss of Urine Past Now Urinate very little
Past Now Urinate a lot Past Now Blood in Urine Past Now Cloudy Urine
Past Now Dark Urine Past Now Red Urine Past Now Tea Colored Urine
Female:    
Past Now Breast Lump Past Now Nipple Discharge Past Now Breast Pain/Tenderness
Past Now Pelvic Pain Past Now Genital Rash Past Now Genital Lesions
Past Now Vaginal Discharge Past Now Vaginal Itch Past Now Vaginal Odor
Past Now Vaginal Pain    
Past Now Bleeding between cycles Past Now Irregular Bleeding Past Now Mid Cycle Pain
Past Now Premenstrual Symptoms:
Past Now Heavy Menses Past Now Menstrual Pain Past Now Menstrual Headache
Past Now Infrequent Menses Past Now Too Frequent Menses Past Now No Menses
Menses onset @ age: ;  Cycle every days;  Lasting for days
Male: Past Now Genital Lesions Past Now Scrotal Rash/Lesions
Past Now Penile Rash/Lesions Past Now Penile Discharge Past Now Testicle Pain
Musculo-Skeletal: Past Now General Aches Past Now Artificial Joint(s)
Past Now Muscle loss (atrophy) Past Now Bone Pain Past Now Limited Motion
Past Now Morning Stiffness Past Now Muscle Pain Past Now Muscle Spasms
Past Now Muscle Weakness Past Now Muscle Twitches Past Now Joints Hurt/Painful
Past Now Joints Stiff Past Now Joints Red Past Now Joint Swelling
Past Now Neck Pain Past Now Mid Back Pain Past Now Low Back Pain
Past Now Sciatica Past Now Arm Pain Past Now Arm Swelling
Past Now Hand Pain Past Now Hand Swelling Past Now Leg Pain
Past Now Leg Cramps Past Now Feet Pain Past Now Feet Burning
Past Now Feet Cramps Past Now Feet Swelling Past Now Flat Feet
Past Now Difficulty with Walking    
Skin/Nails/Hair: Past Now Rashes Past Now Eczema
Past Now Excessive Dry Skin Past Now Itchy Past Now Sweaty
Past Now Redness Past Now Scar(s) Past Now Unusual Texture
Past Now Cracking Past Now Scaling Past Now Moles
Past Now Moles Changing Past Now Increase skin pigment Past Now Loss skin pigment
Past Now Acne Past Now Skin Cancer Past Now Hives
Past Now Warts Past Now Skin Ulcers  
Past Now Brittle Nails Past Now Thickened Nails Past Now Discolored Nails
Past Now Pitted Nails Past Now Inflamed Cuticles Past Now Ingrown Nail
Past Now Fungal Infection Nails Past Now Blue Nails Past Now "Spoon" Shaped Nails
Past Now Dry Hair Past Now Brittle Hair Past Now Oily Hair
Past Now Dandruff Past Now Scalp Itch Past Now Hair Loss
Past Now Increased Hair Growth Past Now Processes/Dye Hair  
Endocrine: Past Now Rapid Growth Past Now Slow Growth
Past Now Overweight Past Now Underweight Past Now Can't Gain Weight
Past Now Can't Lose Weight Past Now Thyroid Goiter Past Now Hot Flashes
Past Now Too Thirsty Past Now No Thirst Past Now Low Blood Pressure
Blood & Lymph: Past Now Easy Bleeding Past Now Prolonged Bleeding
Past Now Blood Clot Past Now Easy Bruising Past Now Frequent Bruising
Past Now Lymph Node Swelling    
Allergy & Environmental: Check those symptoms affected by the following environmental patterns:
Pattern Nose Eye Lung Skin Other Body Symptom
Worse indoors
Improved outdoors
Increased symptoms within 30min of going to bed
Symptoms recur/increase with cold weather
Worse in air conditioning
Worse dusting/sweeping (dust exposure)
Worse outdoors from 4:40-8:30 PM
Worse in cool evening air
Worse damp places
Worse basements
Worse with mold/mildew exposure
Worse raking or exposure to leaves
Worse Sept to heavy/killing frost
Worse outdoors 7-11:00 AM
Improved indoors, esp with air conditioning
Improved with rain
Worse exposure to feed mills
Worse in barns
Pattern Nose Eye Lung Skin Other Body Symptom
Worse after exposure to cats
Worse after exposure to dogs
Worse exposure to other animal:
Insect Reaction, (name insect(s)):
Worse with/after exercise
Worse when hot or overheated
Worse with cold exposure
Present or worse winter
Present or worse spring
Present or worse summer
Present or worse fall
Present all year (all the time)
Worse with storm fronts
Worse with wind
Worse on rainy day
Worse on dry day
Worse with high humidity
Worse from the following Chemical Exposure: Nose Eye Lung Skin Other Body Symptom
Gasoline Products
Exhaust Fumes
Asphalt, Tar
Polishes, Floor Waxes
Moth Balls
Varnish, Paint, Shellac
New Cars
Latex Gloves
Soaps/Detergents
Chlorinated Water
Ammonia
Bleach
Household Cleaners
Disinfectants
Cosmetics
Hair Spray
Perfumes
Air Fresheners
Newsprint
Tobacco Smoke
Metals/Jewelry
Insect Sprays
Rubber Products
Other Chemical(s):

 

Home/School Environment: Complete the following to the best of your knowledge. Skip if unknown
Home Environment
Pets: Dog(s) Cat(s) Other:
Do you live in a: Single house Apartment Mobile Home Other:
Age of the house/place you live: How long have you liverd there?
Live on a farm In a wooded area Near a swamp Near Stream City
Suburbs Near chemical factory/smoke stack Heavy traffic Near power lines/transformers
Did your medical symptoms or problems begin after moving into your current residence? Yes No Don't know
Are your symptoms better when you are away from your current residence? Yes No Don't know
What part of your residence do you feel best? Feel the worst?
In which part of the house do you spend the most time?
Is the Garage: Attached Detached Breezeway Underneath
Is the Basement: Dry Damp Musty Flooded in past Can see mold
Is the Insulation: Fiberglass Cellulose Sawdust Styrofoam Urea foam
Are the Carpets: Wall to Wall Area rugs Cotton Wool Synthetic
Is the Heat: Electric Gas Oil Solar
Forced Hot Air Coal Space Heater Wood Burning Stove
Hot Water Heater: Electric Gas Oil Solar
Air Conditioner: Central Air Room Units
Humidifier: On furnace Room Unit Dehumidifier
Is the Stove: Gas Electric

Is the Dryer:  

Gas Electric
Air Purifier: Central Unit Room Units
   Are the filters: HEPA Charcoal UV lights Fiberglass Electrostatic
Ozone Generator Ionizer

Other:
Other: Use Air Fresheners Use Mothballs Use fluoridated toothpaste
Termite Treatment: No Yes Chemical Name:
Pesticide Use: No Yes Chemical Name:
Lawn Sprays: No Yes

Chemical Name:
School Environment:
At school my symptoms are: Worse Better Same/No Change
Is there any particular place or room at school which bothers you or aggravates your symptoms?
Has the air quality in your school been a concern to your or others?, Explain:
Allergy Testing & Treatments: Complete if you have every had any allergy tests or treatments
1. Have you ever had allergy testing for Airborne Inhalants (dust, molds, grasses, trees, weeds, etc) No Yes
What type? Prick (the skin is just "poked") Scratch Intradermal (injection by needle into skin Blood
Other:
When (Date)? Doctor's Name:
2. Have you ever had allergy testing for Food Allergy? No Yes
What type? Prick (the skin is just "poked") Scratch Intradermal (injection by needle into skin Blood
Elimination/Rechallenge Diet Sublingual (Under tongue) Other:
When (Date)? Doctor's Name:
3. Are you now or have you in the past taken Allergy Shots?No Yes, in past from to
I am presently taking allergy shots, I started my first dose
I receive my shots: 2+ times per week Once per week Every 2 weeks Monthly Seasonally as needed
Any improvements/benefits with the shots? Yes No Don't know
Any reactions to the shots? Yes No Don't know
4. Are you now or have you in the past taken Allergy Drops?NoYes, in past from to
I am presently taking allergy drops, I started my first dose
I receive my drops: times/day Other:
Any improvements/benefits with the drops? Yes No Don't know
Any reactions to the drops? Yes No Don't know
5. Other Allergy Treatments: Elimination/Rotary DietsNAET Other:

 

Growth & Development:
Approximate weight (in pounds) at the following ages:    
1 yr: 2 yrs: 3 yrs: 5yrs: 10 yrs:
Approximate age of first tooth:      
List at what age did your child first performed the following; complete those that apply:
Developmental Milestone Age Developmental Milestone Age
1. Lift Head 8. Spoke Clearly
2. Roll Over 9. Bladder trained
3. Sit Up 10. Bowel trained
4. Stand Up 11. Dry @ night
5. Walk 12. Dresses alone
6. Drank from Cup 13. Rode 2 wheel bicycle
7. Knows Name Not sure about the above but everything seemed on schedule
Formal developmental evaluation was done, which revealed:
Puberty Development, list age of : First Menses: Breast development: Pubic Hair:
Are there any difficulties in sexual adjustment/development?

 

PAST MEDICAL HISTORY:  Answer to the best of your ability, any question you don't know, just leave blank.

Preconception History:       

Was the pregnancy: Planned  Planned, with preconception counseling/education  Unplanned
Was the pregnancy: Wanted   Unwanted  
What form of birth control was used prior to conception?
How long before conception was it discontinued? 
In the six months prior to conception was there any:  
Toxic chemical exposure to mother or father, explain:
Poor diet of mother or father, explain:
Medication use (prescription or over the counter) use by mother or father:
Drug or alcohol use by mother or father, explain:
Infections in mother or father, explain:
Stress in mother or father, explain:
Other medical problems, explain:

Was there any thing else that occurred prior to conception that you feel may be important?

Prenatal (During Pregnancy) History:

Received OB/Midwife Care   Did not received OB/Midwife Care   
Any problems or complication while mother was pregnant with the child?
High blood pressure Diabetes Venereal disease  Measles or other infection
 Smoke cigarettes Use alcohol/ drugs Caffeine use  
 Child was very active in womb  Child had frequent hiccups while in mother's womb
Mother took medications, explain:
Chemical exposure, explain:
Stress during pregnancy, explain:
Abnormal Ultrasound, explain:
Abnormal test during pregnancy:
Other Pregnancy problem, explain:
Birth History:  
Where were you born? (Hospital, City and State):
Was your delivery:  NL Vaginal Delivery  C-section  Forceps  Vacuum used  Breech
 Pitcoin was used  Antibiotics given in labor  Magnesium Sulfate was given in labor
Complications,explain:
When were you delivered:  Term (near/at due date) Early by  wks  Late by  wks
Child’s Blood Type, if known: A+   A-   B+   B-   AB+   AB-  O+  O-
 Circumcision Done    Circumcision not done
Were there any problems while you were in the hospital nursery?
Was in NICU  Breathing problems  Low oxygen   Needed breathing machine (ventilator)
 Infection   Feeding problem  Blood problems (mismatch, Rh, etc)  Jaundice Needed light therapy
Birth Weight: lbs oz Birth Length: inches APGAR: 1 Min: 5 Min:
Medications given to baby:
Other problems, please explain:
Past Illnesses: Check the disease or conditions that apply to you. Please note whether the problem is now, past or both:
Past Now Birth Defects Past Now Genetic Illness  
Past Now Chicken Pox   Past Now Croup   Past Now Measles
Past Now German Measles Past Now German Measles Past Now Polio 
Past Now Rheumatic Fever  Past Now Scarlet Fever Past Now Whooping Cough
Past Now Mono (EBV) Past Now CMV Virus Past Now Coxsackie Virus
Past Now HIV Virus (AIDS) Past Now Lyme Disease Past Now Meningitis
Past Now Attention Deficit Past Now Hyperactivity Past Now Learning Problem
Past Now Dyslexia Past Now Developmental Delay Past Now Depression
Past Now Tension/Anxiety Problem Past Now Post Traumatic Stress Past Now Physical Abuse
Past Now Sexual Abuse Past Now Anorexia Past Now Bulimia
Past Now Migraine Headache Past Now Epilepsy (Seizures)  
Past Now Nearsighted Past Now Farsighted Past Now Wears Glasses
Past Now Lazy Eye Past Now Blindness  
Past Now Deafness Past Now Wears Hearing Aid Past Now Recurrent Ear Infections
Past Now Hayfever/Allergy Past Now  Recurrent Sinus Infection Past Now Nose Polyps
Past Now Dental Problems Past Now Mouth Ulcers/Sores Past Now Recurrent Tonsillitis
Past Now Congenital Heart Disease Past Now Heart Rhythm Problems Past Now Heart Murmur
Past Now Mitral Valve Prolapse Past Now Other Heart Valve Problem  
Past Now Asthma Past Now Recurrent Bronchitis Past Now Pneumonia
Past Now Tuberculosis    
Past Now Acid Reflux Stomach Past Now Stomach Ulcer Past Now Lactose Intolerance
Past Now Colitis Past Now Crohn's Disease Past Now Celiac Disease
Past Now Irritable (Spastic) Bowel Past Now Jaundice Past Now Hernia
Past Now Hepatitis A Past Now Hepatitis B Past Now Hepatitis C
Past Now Dysentery Past Now Parasites Past Now Giardia
Past Now Candida Past Now Worms  
Past Now Bladder Infection Past Now Kidney Infection Past Now Urethral Stricture
Past Now Vaginitis (Yeast) Past Now Vaginitis (Other) Past Now Venereal Disease (VD)
Past Now Muscular Dystrophy Past Now Rheumatoid Arthritis Past Now Lupus (SLE)
Past Now Bone Disease Past Now Sciatica Past Now Whiplash
Past Now Eczema Past Now Atopic Dermatitis Past Now Acne
Past Now Psoriasis Past Now Seborrhea Past Now Athletes Foot
Past Now Ringworm    
Past Now Diabetes Past Now Hypoglycemia Past Now Weight Problem
Past Now Hyperthyroidism (High) Past Now Hypothyroidism (Low) Past Now Adrenal Problem

Past Now Blood Disease

 Past Now Anemia Past Now Sickle Cell Disease
Past Now Thalassemia Past Now Hemophilia Past Now Blood Transfusion
Past Now Immune Deficiency Past Now Leukemia Past Now Lymphoma
Past Now Cancer or Tumor    

 

List any other past or present illnesses:
Please list handicaps/disabilities:
If you were ever hospitalized for at least one overnight stay (but did NOT involve surgery or child birth), please describe:

 

OPERATIONS/SURGERIES: Please list your major operations, including same day surgery. List the name of operation, date it occurred, your age, the reason for the operation, name of the hospital, city and state, and any complications (include any anesthesia reactions). Start with early childhood and list in order to the most recent:
Operation Date Age Reason/Complication Hospital
Ex: Tonsillectomy 02/20/1962 5 Recurrent sore throats Shriners

 

INJURIES: List any past injuries you have had (not including those stated in the current problem section). Include the type of injury (car accident, fall, broken bones, machinery/occupation accident, etc), the date it occurred, your age, and any treatment given. Please list from oldest injury to most recent:
Injury Date Age How Injury Occurred Treatment Given
Ex: Neck Sprain 02/20/1962 20 Car Accident Chiropractic
 

HEALTH CARE MAINTENANCE: Please list when you last had the following tests, date, age, location, and the result if known:
Test Date Result
Dental Exam
Hearing Test
Eye Exam/Vision Test
Cholesterol
Tuberculosis (TB) Test

 

IMMUNIZATIONS: Please list the date and age of any immunization or vaccine you have received and any reaction you may have had (you may bring list on separate sheet from another’s physician’s office if available):
Immunization Date Reaction Immunization Date Reaction
DTaP#1 MMR#1
DTaP#2 MMR#2
DTaP#3 PCV (Pneumococcal)#1
DTaP#4 PCV (Pneumococcal)#2
DTaP#5 PCV (Pneumococcal)#3
TetanusBooster (DT) PCV (Pneumococcal)#4
Hib (H.flu)#1 Chickenpox#1
Hib (H.flu)#2 Chickenpox#2
Hib (H.flu)#3 Meningococcal
Hib (H.flu)#4 Last Flu shot
Hepatitis B#1

Others:
Hepatitis B#2
Hepatitis B#3
Polio#1
Polio#2
Polio#3
Polio#4

 

FAMILY HISTORY: Family background may be related to medical conditions. Please fill in all of the following chart to the best of your ability, you may wish to call certain relatives for information if needed. State their first name, mark if the they are deceased (X), the age they died, their ethnic background (of your grandparents and parents), cause of death and lastly any medical conditions or illnesses they have had or currently have. You may wish to refer to the list of medical illnesses on page 3 to see if any apply to your family history. Be sure to include genetic or birth defects, mental retardation, or any other unusual disease. You should also include other family members with significant medical history, (Ex. maternal aunt with breast cancer). Circle all those who live with you now.
Family Member Name Deceased Age Ethnic Cause of Death Illnesses
Example Bill

X

 72 Hispanic Heart Attack Diabetes, High Cholesterol, Prostate Cancer
Mother'sMother
Mother's Father
Natural Mother
Father's Mother
Father's Father
Natural Father
Brother's & Sisters: start with the oldest and include yourself, place a * next to your name. Do not list your illnesses, jus those of your family members