pediatric intake form pediatric patient questionnaire.pdfku integrative medicine | 3901 rainbow...

KU Integrative Medicine | 3901 Rainbow Blvd, MS 1017 | Kansas City, KS 66160 | (913) 588-6208 | Fax (913) 588-0012 http://integrativemed.kumc.edu | E-mail: [email protected] 02042013

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Pediatric Intake Form

Name_________________________________________________________________________ Preferred Name: __________________________________ (last) (First) (middle) Date of Birth_______________________________________ Birthplace_________________________________________________________ Sex M/F (month) (day) (year) Height __________ Weight: Now _____________ One year ago ___________ Maximum ____________ When ___________________________ Street Address _____________________________________________________________________________________________________________________ (street name and number) (city) (state) (zip) Home Phone __________________________ In Case of Emergency Notify: _______________________________ Relationship: ____________________ Phone: ________________________ Mother’s Name: ________________________________________________________ Phone: __________________________________________________ Mother’s e-mail address: ______________________________________ Father’s e-mail address: ______________________________________ Father’s Name ___________________________________________________________ Phone _________________________________________________ If parents separated, child’s primary legal residence is with whom? Name: ___________________________________________________________________ Relationship: ___________________________________________ Address: _________________________________________________________________ Child’s Legal Guardian(s): ____________________________

Care Provider Information: Primary Care Provider: ________________________________________________ Phone: ___________________________________________________

Address: _____________________________________________________________________________________________________________________________ Pharmacy: ______________________________________________________________ Phone: __________________________________________________ Additional Specialists Working with Your Child

______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ We do not submit insurance. At the time of your payment, you will get a copy of your charge sheet and a receipt that you may submit to your insurance company for reimbursement.

Signature ____________________________________________________________________ Date ________________________________________________


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Reason for visit: ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________

How did you hear about the Program in Integrative Medicine? _______________________________________________________________

Your child’s health concerns in order of importance: __________________________________________________________________________ What do you and your child hope to get out of today’s visit? __________________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ Has your child tried complementary, integrative or alternative medicine therapies? ______________________________________ If yes, please fill out chart below.

Name of Therapy:

Condition

Frequency and Duration of Use:

Improvement Seen?

Still Using Therapy?

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

List Child’s Hospitalizations and Surgeries

Surgery/Hospitalization: Month/Year: Reason:

Please list Major Trauma of Child (Car accident, head injury, fall)

Event: Date:

Dental History

Dental Procedures (root canals/fillings-type?/surgeries) Date:


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Mark location of any pain (if applicable): Indicate pain location your child experiences with an “X” below. If whole areas are affected, then shade in the painful area.

How often does your child have pain? Constantly (100% of the time) Nearly constantly (60 to 95% of the time) Intermittently (30 to 60% of the time) Occasionally (less than 30% of the time)

Has Your Child Taken Antibiotic, Antifungal or Antiparasite Medication Before? (If yes, how many times?)

Name of Medicine: Month/Year Taken: Condition Dosage and Length of Treatment:

Has Your Child Taken Anti-depressants, Anti-psychotics, Stimulants or ADHD Medication Before? (If yes, how many times?)

Name of Medicine: Month/Year Taken: Condition Dosage and Length of Treatment:

Please List Child’s Sensitivities/Allergies/Reactions

Drug/Food/Environmental Trigger Reaction Age of Child at First Reaction


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Has Your Child Had Any of the Following?

Tests/Evaluations: Date: Results:

EEG/qEEG

Speech/language test

Assessment for learning disability

MRI/CT

Endoscopy/Colonoscopy

Xray

Audiology/Hearing test

Other:

Prenatal and Birth History Mother’s age at time of birth: _______ Amount of weight gained during pregnancy? ______ Mother’s health during pregnancy: Abnormal bleeding Diabetes Tobacco use

Nausea Hypertension Alcohol use

Physical or emotional trauma Infection Drug use

Medications Thyroid problems Postpartum depression

Medications taken during pregnancy: ___________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ Weeks Gestation: ______ Full-term Premature Late Length of labor: ______ Any complications with labor or deliver? __________________________________________________________ Type of birth (check all that apply): vaginal induced c-section anesthesia used forceps breech Birth weight: ______ Birth length: ______ Head circumference: ______ Apgar Score: ______ Multiple Birth? Y/N #Multiples: ______ Birth order: ______ Birth Defects: ____________________________________ Prenatal complications: __________________________________________________________________________________________________________ Perinatal complications: __________________________________________________________________________________________________________ Postnatal complications: _________________________________________________________________________________________________________

Infant Feeding History

Was your child breastfed? Y/N If yes, how long? ____________________ Was your child fed infant formula? Y/N What age did your child start and stop formula? Start ______ Stop ______ What age did your child start solid foods? ______ Any feeding issues during infancy or early childhood? Y/N Please explain issues: _____________________________________________________________________________________________________________


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Vaccinations/Immunizations

Disease: Please choose: D: child had disease I: child has been immunized/vaccinated N: neither

Meningococcal (meningitis)

DTaP (diptheria, tetanus, pertussis)

Hepatitis B

Hepatitis A

Rotavirus

Polio

Haemophilus influenzae type B

Pneumococcal (pneumonia)

Influenza

Measles, Mumps, Rubella

Human Papillomavirus

Chicken Pox (varicella)

Please indicate your child’s symptom history below

Constitutional Hematologic/Lymphatic

Good general health lately Yes No Slow to heal after cuts Yes No

Recent weight change Yes No Bleeding or bruising tendency Yes No

Decreased Appetite Yes No Anemia Yes No

Fever/night sweats Yes No Blood clots Yes No

Fatigue/weakness Yes No Blood transfusion Yes No

Headaches Yes No Enlarged glands Yes No

Body/Body Odor Yes No Other: Yes No

Eyes Endocrine

Eye disease or injury Yes No Glandular or hormone problem Yes No

Wears glasses or contacts Yes No Thyroid disease Yes No

Blurred or double vision Yes No Diabetes Yes No

Ear/Nose/Throat Genitourinary

Hearing loss or ringing Yes No Frequent urination Yes No

Earaches or frequent ear infections Yes No Burning or painful urination Yes No

Chronic sinus problems Yes No Blood in urine Yes No

Nose bleeds Yes No Bedwetting Yes No

Mouth sores Yes No Urinary/Stool Incontinence Yes No

Bleeding gums Yes No Genital/Anal Sores or discharge Yes No

Sore throat or strep Yes No Painful/irregular periods; Age started: Yes No

Tonsillitis Yes No Any pregnancies? #____ Yes No

Oral Thrush Yes No Any miscarriages? #____ Yes No

Respiratory Gastrointestinal

Chronic or Frequent coughs Yes No Change in bowel movements Yes No

Spitting up blood Yes No Nausea or vomiting Yes No

Shortness of breath Yes No Frequent diarrhea Yes No

Asthma Yes No Painful bowel movements Yes No

Wheezing Yes No Rectal bleeding/blood in stool Yes No

Bronchitis Yes No Stomach aches Yes No

Pneumonia Yes No Stomach ulcers Yes No

Cardiovascular Neurological

Heart trouble Yes No Frequent or recurring headaches Yes No

Chest pain Yes No Lightheaded or dizzy Yes No

Heart murmur Yes No Convulsions or seizures Yes No

Palpitation Yes No Tremors or Shakes Yes No

Other: Head injury Yes No


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Integumentary Musculoskeletal

Frequent Rashes Yes No Joint Pain Yes No

Eczema or psoriasis Yes No Joint stiffness or swelling Yes No

Acne Yes No Weakness of muscles or joints Yes No

Hives Yes No Muscle pain or cramps Yes No

Change in skin color Yes No Back pain Yes No

Change in hair or nails Yes No Difficulty walking Yes No

Fungal infection (athlete’s foot, ringworm) Yes No Numbness in hands or feet Yes No

Breast lump or discharge Yes No Other:

Psychiatric/Behavioral/Sleep

Anxiety/nervousness Yes No Wakes frequently Yes No

Depression Yes No Nightmares Yes No

Unusual Fears Yes No Sleeps too much Yes No

Behavioral problems Yes No Awakes feeling fatigued Yes No

Short attention span Yes No Difficulty waking Yes No

Restlessness Yes No Falls asleep during the day Yes No

Aggressive to self or others Yes No Thoughts of harm to self or others Yes No

Short temper Yes No Other:

Family Medical History Have any blood relatives of the child (grandparents, parents and siblings) been diagnosed with any of the following symptoms or conditions? If yes, please indicate who and age at which they were diagnosed. (please indicate mother or father’s side of family as well)

Disease Condition Relationship to Patient Age diagnosed Living?

Alcohol and/or Chemical Dependency Yes/No Age at death:

Allergies (seasonal, food, drug, environmental) Yes/No Age at death:

Anemia Yes/No Age at death:

Anxiety or Panic Attacks Yes/No Age at death:

Asthma Yes/No Age at death:

ADD/ADHD Yes/No Age at death:

Arthritis (joint problems) Yes/No Age at death:

Autism Yes/No Age at death:

Autoimmune condition; type: Yes/No Age at death:

Cancer; type: Yes/No Age at death:

Chronic Fatigue Syndrome Yes/No Age at death:

Chronic Pain or Fibromyalgia Yes/No Age at death:

Depression Yes/No Age at death:

Diabetes or Insulin Resistance Yes/No Age at death:

Eye Disease; please name: Yes/No Age at death:

Food Allergies or Sensitivities Yes/No Age at death:

Frequent Headaches; Type(s): Yes/No Age at death:

Gallbladder Disease Yes/No Age at death:

Genetic or Congenital Disorders Yes/No Age at death:

Heart or Vascular Disease Yes/No Age at death:

Hepatitis Yes/No Age at death:

Hypoglycemia (low blood sugar) Yes/No Age at death:

High blood pressure (hypertension) Yes/No Age at death:

High cholesterol, dyslipidemia Yes/No Age at death:

Intestinal Disease; type: Yes/No Age at death:

Infection; type: Yes/No Age at death:

Inflammatory or Irritable Bowel Syndrome Yes/No Age at death:

Insomnia Yes/No Age at death:

Kidney disease or failure Yes/No Age at death:


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Disease Condition Relationship to Patient Age diagnosed Living?

Learning Disability Yes/No Age at death:

Liver disease Yes/No Age at death:

Lung Problems Yes/No Age at death:

Memory Loss or Dementia Yes/No Age at death:

Obesity Yes/No Age at death:

Osteoporosis/osteopenia Yes/No Age at death:

Polycystic Ovarian Syndrome Yes/No Age at death:

Prostate problems Yes/No Age at death:

Psychiatric Conditions (bi-polar, schizophrenia, depression, OCD)

Yes/No Age at death:

Rashes or skin conditions Yes/No Age at death:

Seizures or epilepsy Yes/No Age at death:

Stroke Yes/No Age at death:

Thyroid issues (hypo- or hyperthyroid) Yes/No Age at death:

Other:

Brothers and Sisters

Name: Age: Grade: Relation to Child (half, full, step): Where living?

Lifestyle and Social History My child typically goes to bed at: ________ and typically wakes at:________ My child typically gets ______ hours of sleep per night Comments: __________________________________________________________ My child’s favorite activities are: ________________________________________________________________________________________________ My child is involved in the following exercise activities or sports: Activity:___________________________________ Frequency:________________________________ Duration:_______________ Activity:___________________________________ Frequency:________________________________ Duration:_______________ Activity:___________________________________ Frequency:________________________________ Duration:_______________ My child watches _____ hours of television per day / week (please circle one). My child plays on the computer or plays video games _____ hours of per day / week (please circle one). How often does you child read, or how often does someone read to your child? daily several times a week weekly less than weekly


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Does anyone in your child’s household smoke? Yes No Has your child been exposed to or used street drugs? Yes No Has your child been exposed to or used alcohol? Yes No

Are there animals in the home? Yes No If yes, what?_____________________________________________________________ Do you know of any toxins or other hazards that your child is regularly exposed to (in home, school, workplace, hobby)? Yes No Please describe: ___________________________________________________________________________________ How would you describe the emotional climate of your child’s home? ______________________________________________________ Development History At what age did your child: Sit alone: ________ Walk alone: _________ Talk in sentences: _______ Toilet trained: _______ School information: Name of School: ________________________________________________________ Current Grade: _____________

Grades on last report card: _____________ How many school days missed this year:________

Growth History Have your child had any recent changes in his or her weight that you are concerned about? Yes No If yes, please explain:______________________________________________________________________________________________________________ Has your child had a history of poor growth? Yes No If yes, please explain: __________________________________________ Digestion How many times a day does your child have a bowel movement? __________

Would you describe your child’s stools as hard, soft, or loose? (circle one) How often does your child experience:

Gas? Often Sometimes Rarely Bloating? Often Sometimes Rarely Stomach Pain? Often Sometimes Rarely

Nausea/Vomiting? Often Sometimes Rarely Diarrhea? Often Sometimes Rarely Constipation/Straining? Often Sometimes Rarely


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Do you associate any of your child’s digestive symptoms with eating certain foods? Yes No Please explain:_____________________________________________________________________________________________________________________ Nutritional History What are your child’s nutrition and health goals?______________________________________________________________________________ Is there anything that holds your child back from attaining his or her health and nutrition goals? ______________________________________________________________________________________________________________________________________ What, if anything, has your child tried in the past to manage his or her nutrition related concerns? ______________________________________________________________________________________________________________________________________

Food Preferences Is your child following a special diet or does he or she have specific dietary limitations or needs based on health, ethnic, cultural, or religious preferences? Yes No Please explain:_____________________________________________________________________________________________________________________ Please list any food allergies, sensitivities, and/or intolerances: _____________________________________________________________ ______________________________________________________________________________________________________________________________________ Food cravings:_____________________________________________________________________________________________________________________ Food dislikes:______________________________________________________________________________________________________________________ Which dietary choices or habits do you feel your child feel is most challenged by? ______________________________________________________________________________________________________________________________________ Who is involved in preparing food for and feeding your child? Check all that apply. � Self � other parent � school � daycare � in-home care �grandparent Who does the food shopping for your household? _____________________________________________________________________________ Where is food shopping done? ___________________________________________________________________________________________________


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How often does your child eat the following foods: Once daily 2-3 times daily Once Weekly 2-3 time weekly

2-3 times monthly

Fast food Where?

Vending machine foods What?

School Cafeteria

Daycare/Other Caretaker’s home

Full service restaurant Where?

Frozen meals What?

Home Cooked Meals

Dietary Intake Which of the following beverages does your child drink and how much? Water: � tap � bottled How much? _______day _______week_______month Juice: � natural � fruit drinks How much? _______day _______week_______month Soda: � regular � diet How much? _______day _______week_______month Milk: � whole � 2% � 1% � skim How much? _______day _______week_______month Milk alternative: Type:_______________ How much? _______day _______week_______month


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How often does your child eat the following foods:

Once daily 2-3 times daily Once Weekly 2-3 time weekly 2-3 times monthly

Hamburger/Ground Beef

Steak

Liver

Veal

Ham

Pork Chop/Tenderloin

Bacon

Lamb

Chicken

Turkey

Deli meat; type:

Fish; type:

Soyfoods; type:

Beans; type:

Cereal; type:

Bread; type:

Crackers; type:

Foods made with white flour Type:

Whole Grains Type:

Fresh/Raw Vegetables

Cooked Vegetables

Fruit

Margarine

Butter

Cheese


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How often does your child eat the following foods:

Once daily 2-3 times daily Once Weekly 2-3 time weekly 2-3 times monthly

Yogurt

Olive oil

Vegetable oil; type:

Mayonnaise

Salad Dressing; type:

French Fries

Potato Chips

Tortilla Chips

Fried Chicken

Fried Fish

Foods with added sugars/high fructose corn syrup; type:

Foods with hydrogenated oils/trans-fats

Artificial Sweeteners

Cookies, Cakes, Candy


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Medication/Supplement List How many times and at what ages have you taken

Infancy Childhood Teen Adulthood

Antiobiotics _____________ _____________ _____________ _____________

Steroids _____________ _____________ _____________ _____________

Include non-prescription drugs as well as vitamins, minerals, and other nutritional supplements. Indicate the mg or IUs and the form (e.g. calcium vs. calcium lactate) when possible.

Supplements / Medications Dose Units Frequency Start Date Stop Date

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pediatric intake form pediatric patient questionnaire.pdfku integrative medicine | 3901 rainbow...

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