Pediatric Intake Form - Natural Medicine in Kent, WA

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

Date:

PEDIATRIC/ADOLESCENT PATIENT PROFILE

Patient’s Name:

Age:

Sex:

Birthdate:

Address:

City:

State:

Zip:

Mother’s Name:

Father’s Name:

Best email address?

Phone (home):

(Work): mother/father/other

How did you hear about us?

Child’s Primary Care Physician:

Person To Be Notified In Case of Emergency:

Name:

Relationship:

Insurance information:

Name of the insurance company?

Subscriber’s name (This could be the child or his/her parents)?

Subscriber’s employer?

Subscriber’s 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 worst/highest level)?

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

Anything else important about this problem you’d 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 worst/highest level)?

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

Anything else important about this problem you’d 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 worst/highest level)?

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

Anything else important about this problem you’d 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 worst/highest level)?

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

Anything else important about this problem you’d 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 worst/highest level)?

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

Anything else important about this problem you’d 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 worst/highest level)?

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

Anything else important about this problem you’d like to share?

If you have other problems you’d 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:

HOSPITALIZATIONS / SURGERIES / ACCIDENTS / SERIOUS INJURIES:

Describe each incident and give date & age:

MEDICATIONS TAKEN IN THE LAST 5 YEARS:

(Include dates and duration):

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

(Include dates and duration):

SOCIAL HISTORY:

1) Parents: SingleMarriedSeparatedDivorced

Mother’s Occupation

Full TimePart Time

Father’s Occupation

Full TimePart Time

2) Other Guardian:

Relationship

3) Others Residing in Home:

Relationship

4) Siblings:

Name:	Age:	HEALTH PROBLEMS:

CHILD’S HEALTH HISTORY (please check)
Condition	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:

MOTHER’S 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 child’s favorite foods?

3) What is your child’s 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
MOTHER’S 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 CHILD’S HEALTH?

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