Children’s Form – Apple Naturopathic and Medical Aesthetics

Patient's name:*

First

Last

Date of first visit:

Age:

Date of Birth:

day

/

month

/

year

Gender:

Parent 1:

First

Last

Parent 2:

First

Last

Address:

Address City Province Postal Code

Phone # (home):

Area Code

-

Phone Number

Phone # (work):

Area Code

-

Phone Number

E-mail:

How did you hear about our Clinic?

Name of Dr.'s Office/Hospital/Clinic where your child's health records are kept:

Reason for referral or presenting problems:

MEDICATIONS

Aspirin

Now

Past

Tylenol

Now

Past

Decongestant

Now

Past

Ibuprofin

Now

Past

Antibiotics

Now

Past

Anti-histamine

Now

Past

Other

Now

Past

Please list other medications:

Allergies to medicines:

Approx. no. times had tonsillitis:

Approx. no. of ear infections:

Has your child had any of the following tests? Please list when, where and the results.

Electroencephalogram:

Psychological evaluation:

Hearing:

Speech/Language:

Injuries/Surgeries/Hospitalizations (please list):

Any adverse reactions?

If yes, please explain:

PRENATAL HISTORY

Previous pregnancies by natural mother, miscarriages, or complications?

Mother's age at child's birth?

BIRTH HISTORY

Term:

Weight at birth:

Length of labor:

Complications?

Child's sleep patterns (first year)

Food intolerances (if any):

Feeding: Breast fed?

How long?

Formula:

Age began solids:

Which foods?

Age began sitting:

Age began crawling:

Age began walking:

Age began talking:

Hives:

Eczema

Bleeding gums

Nose bleeds

Acne

High fevers

Chronic rash

Hearing loss

Diarrhea

Sore throats

Headaches

Frequent Colds

Wheezing

Cough

Burning of urine

Frequent urination

Heart murmur

Vomiting spells

Anemia

Stomach aches

Jaundice

Easy bruising

Flat feet

Constipation

Gas

Bleeding tendency

Joint pains

Dizzy spells

Bloody urine

Cries easily

Nervous

Sleep problems

Night sweats

Sensitive to light

Body/breath odor

Motion/car sickness

No appetite

Nightmares

Canker sores

Unusual fears

Excessive fatigue

Hair loss

DIET
Please describe your child's typical daily diet:

Breakfast:

Lunch:

Dinner:

Snacks:

To Drink:

Extra Notes:

Thank you. I look forward to helping your child in any way I can.

Word Verification: