test Patient's name:*FirstLast Date of first visit: Age: Date of Birth:01020304050607080910111213141516171819202122232425262728293031day / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecembermonth / 20212020201920182017201620152014year Gender:please selectfemalemale Parent 1:FirstLast Parent 2:FirstLast 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 AspirinNowPast TylenolNowPast DecongestantNowPast IbuprofinNowPast AntibioticsNowPast Anti-histamineNowPast OtherNowPast Please list other medications: Allergies to medicines: MEDICAL HISTORY (check all that apply)Chicken poxScarlet feverTonsillitisMeaslesPneumoniaEar InfectionsMumpsFrequent coldsother, please listRubellaRheumatic fever 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): IMMUNIZATIONS:MeaslesPolioMMRSmallpoxDiphtheriaMumpsDPTTetanusOther (please list)Influenza Any adverse reactions?Select valueNOYES If yes, please explain: FAMILY HISTORY:Heart DiseaseDiabetesBirth defectsCancerHypertensionArthritisMental illnessAllergiesPRENATAL HISTORY Previous pregnancies by natural mother, miscarriages, or complications? Mother's age at child's birth? Mother's health during pregnancy? (check all that apply)BleedingPhysical or emotional traumaNauseaCigarettes, alcohol, drug consumptionIllnessesMedicationsHypertensionThyroid problemsDiabetesBIRTH HISTORY Term:Select valueFullPrematureLate Weight at birth: Length of labor: Complications? Did your child have any of the following problems shortly after birth?Birth defectsBirth injuriesBlue babyCerebral palsySeizuresJaundiceColicFeverRashesother (please explain) Child's sleep patterns (first year) Food intolerances (if any): Feeding: Breast fed?Select valueYESNO How long? Formula:Select valueYES - milkYES - soyNO Age began solids: Which foods? Age began sitting: Age began crawling: Age began walking: Age began talking: Hives:YP EczemaYP Bleeding gumsYP Nose bleedsYP AcneYP High feversYP Chronic rashYP Hearing lossYP DiarrheaYP Sore throatsYP HeadachesYP Frequent ColdsYP WheezingYP CoughYP Burning of urineYP Frequent urinationYP Heart murmurYP Vomiting spellsYP AnemiaYP Stomach achesYP JaundiceYP Easy bruisingYP Flat feetYP ConstipationYP GasYP Bleeding tendencyYP Joint painsYP Dizzy spellsYP Bloody urineYP Cries easilyYP NervousYP Sleep problemsYP Night sweatsYP Sensitive to lightYP Body/breath odorYP Motion/car sicknessYP No appetiteYP NightmaresYP Canker soresYP Unusual fearsYP Excessive fatigueYP Hair lossYPDIETPlease 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:SubmitReset