Pediatric Intake Form - Natural Medicine Bellevue, Kent

Whole Health Clinic
Dr. Sharum Sharif, N.D
6632 S. 191st Place, Suite E-110; Kent, WA 98032
(425) 656-0700 â Fax (425) 656-0705

Date:

PEDIATRIC/ADOLESCENT PATIENT PROFILE

Patientâs Name:

Age:

Sex:

Birthdate:

Address:

City:

State:

Zip:

Motherâs Name:

Fatherâs Name:

Best email address?

Phone (home):

(Work): mother/father/other

How did you hear about us?

Childâs Primary Care Physician:

Person To Be Notified In Case of Emergency:

Name:

Relationship:

Insurance information:

Name of the insurance company?

Subscriberâs name (This could be the child or his/her parents)?

Subscriberâs employer?

Subscriberâs date of birth?

PLEASE LIST THE HEALTH CONCERN/PROBLEM THAT BRINGS YOU IN TODAY:

Problem or diagnosis #1)

When did this problem initially start to bother your child?

How often does it bother your child- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem youâd like to share?

Problem or diagnosis #2)

When did this problem initially start to bother your child?

How often does it bother your child- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem youâd like to share?

Problem or diagnosis #3)

When did this problem initially start to bother your child?

How often does it bother your child- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem youâd like to share?

Problem or diagnosis #4)

When did this problem initially start to bother your child?

How often does it bother your child- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem youâd like to share?

Problem or diagnosis #5)

When did this problem initially start to bother your child?

How often does it bother your child- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem youâd like to share?

Problem or diagnosis #6)

When did this problem initially start to bother your child?

How often does it bother your child- hourly, daily, weekly, monthly?

How severe on a scale of zero to 10 (10 being the worse/highest level)?

What makes this problem better or worse, namely drugs or supplements, etc.?

Anything else important about this problem youâd like to share?

If you have other problems youâd like to share with us, please type them up on a separate sheet of paper in the same format as above.

HISTORY OF THIS CONCERN/PROBLEM:

1. Has child received any treatment for this illness? YesNo

If Yes, What

2. Has child ever had this illness in the past? YesNo

If Yes, When

3. How long has he/she had this illness?

MEDICATIONS:

now

past

frequency

Aspirin

Tylenol

Antibiotics

Decongestants

Other

SUPPLEMENTS:

now

past

frequency

Vitamins

Minerals

Fluoride

Herbs

Allergies to drugs or medications: [text-82]

HOSPITALIZATIONS / SURGERIES / ACCIDENTS / SERIOUS INJURIES:

Describe each incident and give date & age: [text-83]

MEDICATIONS TAKEN IN THE LAST 5 YEARS:

(Include dates and duration): [text-84]

IMMUNIZATIONS: (List types, dates given, and any adverse reactions)

(Include dates and duration): [text-85]

SOCIAL HISTORY:

1) Parents: SingleMarriedSeparatedDivorced

Motherâs Occupation [text-90332]

Full TimePart Time

Fatherâs Occupation

Full TimePart Time

2) Other Guardian:

Relationship

3) Others Residing in Home:

Relationship

4) Siblings:

Name:	Age:	HEALTH PROBLEMS:

CHILDâS HEALTH HISTORY (please check)

Now

Past:

NEVER

Acne

Allergies

Anemia

Asthma

Bed Wetting

Birth Defects

Colic

Constipation

Cough/Wheeze

Cradle Cap

Depression

Diarrhea

Dizzy Spells

Earaches

Eczema

Epilepsy/Seizures

Fatigue

Frequent Infections

Headaches

Heart Murmur

High Fever

Hyperactivity/ ADD

Insomnia

Jaundice

Learning Difficulties

Moodiness

Stuffy Nose

Thrush

Vomiting Spells

Other

CHILDHOOD ILLNESSES (Please check and indicate at what age)

Chicken pox

Measles

Mumps

Rubella

Whooping Cough

Scarlet Fever

Rheumatic Fever

Strep Throat

Pneumonia

Asthma

Mononucleosis

Ear Infections

Tonsillitis

Croup

other

FAMILY HISTORY: Identify all family members who have or have had any of the following:

Alcoholism

Allergies

Anemia

Arthritis

Asthma

Birth Defects

Cancer

Diabetes

Eczema

Epilepsy

Stroke

Obesity

High Blood Pressure

Hypoglycemia

Mental Illness

Thyroid disorder

Heart Disease

Hearing Loss

Other (Describe)

PRENATAL/ BIRTH HISTORY:

MOTHERâS health during the pregnancy with this INFANT/ CHILD/ ADOLESCENT (check and describe in space provided) :

Age

Trauma/Injury

Alcohol Consumption

Illness

Bleeding

Stress

Nausea

Drugs

Smoking

X-rays

High Blood Pressure

Toxemia

Medications

Other

Describe:

TERM: FullPrematureLate

Birth Weight:

LBS

OZ

Was birth / pregnancy: EasyDifficult

Place of Birth: HospitalHomeClinicother

Method

HABITS:

1) Does your child eat a special diet?

2) What are your childâs favorite foods?

3) What is your childâs general disposition?

4) How much does your child sleep?

5) Does your child wear: cloth diapersDisposableNone

6) Date of last check-up

with Dr

7) List any chemicals, metals, dusts, smoke or fumes your child has been repeatedly exposed to:

8) Does your child react to pollens? If so, then which ones?

9) Does your child react to foods? If so, then which ones?

(Check appropriate boxes)

FEEDING:	CHOOSE APPROPRIATE BOXES	TIMES PER DAY
MOTHERâS MILK (or weaned when?: )	NEVERRARELYFREQUENTLYWEEKLY	1X2X3X4X
MILK OR FORMULA (Kind)	NEVERRARELYFREQUENTLYWEEKLY	1X2X3X4X
SUGAR SWEETS	NEVERRARELYFREQUENTLYWEEKLY	1X2X3X4X
FRUIT SWEETENERS	NEVERRARELYFREQUENTLYWEEKLY	1X2X3X4X
WHITE FLOUR	NEVERRARELYFREQUENTLYWEEKLY	1X2X3X4X
PROTEIN FOODS	NEVERRARELYFREQUENTLYWEEKLY	1X2X3X4X


VITAMINS-MINERALS (KIND)	NEVERRARELYFREQUENTLYWEEKLY	1X2X3X4X
ASPIRIN	NEVERRARELYFREQUENTLYWEEKLY	1X2X3X4X
LAXATIVES	NEVERRARELYFREQUENTLYWEEKLY	1X2X3X4X

ARE YOU WILLING TO CHANGE YOUR HABITS TO HELP IMPROVE YOUR CHILDâS HEALTH?

DOES YOUR CHILD HAVE ANY OTHER PROBLEMS YOU WOULD LIKE TO DISCUSS WITH THE DOCTOR?