"Pediatric Intake Form" - Colorado

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Download "Pediatric Intake Form" - Colorado

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Monica Edlauer, MSOM, LAc.
2955 Valmont St, Ste. 100,
Boulder, CO 80301
(303) 859-7556
Pediatric Intake Form
Patient's name: ______________________________________Date of first visit: ______________
Age: Date of Birth (month/day/year): _____/_____/_____ Gender:
female
male
Mother's name: _______________________Father's name:________________________________
Address: ____________________________City:____________________ Zip: ________________
Phone # (home): (_____)________________ Parent’s work/cell phone # (_____)_______________
Parent’s e-mail address: ____________________________________________________________
Child’s GP or Pediatrician: __________________________________________________________
Current health concerns: __________________________________________________________
_______________________________________________________________________________________
MEDICAL HISTORY
Chicken pox ____ Scarlet fever _____ Roseola _____ Mononucleosis ______ Measles _____ Pneumonia
_____Strep throat _____ Impetigo_____ Mumps _____ Whooping Cough _____ Ear Infections_____
Rubella _____ Rheumatic fever_____ other (please list) ___________________________________
________________________________________________________________________________________
What screening tests has your child had? (blood, hearing, vision, etc)__________________________
Serious Illnesses/Injuries/Surgeries/Hospitalizations (please list): ___________________________
________________________________________________________________________________________
Please list all current medications (prescription, over the counter, vitamins, herbs, homeopathics, etc.)
_______________________________________________________________________________
_______________________________________________________________________________
Please list any past prescription medications: _____________________________________________
_______________________________________________________________________________
IMMUNIZATIONS
MMR _____ Polio _____ Prevnar _____ Chicken Pox _____ H. Influenza B _____ DTaP _______ Influenza
_____ Hepatitis B _____ Hepatitis A _____ Other: __________________________
Any adverse reactions to vaccines:
yes
no If yes, please describe: ___________________________
________________________________________________________________________________
FAMILY HISTORY
Heart disease ____ Diabetes____ Birth abnormality ____ Celiac disease ____ Hypertension ____
Arthritis ___Tuberculosis ___ Eczema____ Cancer _____Allergies ____ Mental illness _____ Asthma____
Other: __________________________________________________________
BIRTH MOTHER’S PRENATAL HISTORY
Mother's age at child's birth? _____ Mother's health during pregnancy? _________________________
Monica Edlauer, MSOM, LAc.
2955 Valmont St, Ste. 100,
Boulder, CO 80301
(303) 859-7556
Pediatric Intake Form
Patient's name: ______________________________________Date of first visit: ______________
Age: Date of Birth (month/day/year): _____/_____/_____ Gender:
female
male
Mother's name: _______________________Father's name:________________________________
Address: ____________________________City:____________________ Zip: ________________
Phone # (home): (_____)________________ Parent’s work/cell phone # (_____)_______________
Parent’s e-mail address: ____________________________________________________________
Child’s GP or Pediatrician: __________________________________________________________
Current health concerns: __________________________________________________________
_______________________________________________________________________________________
MEDICAL HISTORY
Chicken pox ____ Scarlet fever _____ Roseola _____ Mononucleosis ______ Measles _____ Pneumonia
_____Strep throat _____ Impetigo_____ Mumps _____ Whooping Cough _____ Ear Infections_____
Rubella _____ Rheumatic fever_____ other (please list) ___________________________________
________________________________________________________________________________________
What screening tests has your child had? (blood, hearing, vision, etc)__________________________
Serious Illnesses/Injuries/Surgeries/Hospitalizations (please list): ___________________________
________________________________________________________________________________________
Please list all current medications (prescription, over the counter, vitamins, herbs, homeopathics, etc.)
_______________________________________________________________________________
_______________________________________________________________________________
Please list any past prescription medications: _____________________________________________
_______________________________________________________________________________
IMMUNIZATIONS
MMR _____ Polio _____ Prevnar _____ Chicken Pox _____ H. Influenza B _____ DTaP _______ Influenza
_____ Hepatitis B _____ Hepatitis A _____ Other: __________________________
Any adverse reactions to vaccines:
yes
no If yes, please describe: ___________________________
________________________________________________________________________________
FAMILY HISTORY
Heart disease ____ Diabetes____ Birth abnormality ____ Celiac disease ____ Hypertension ____
Arthritis ___Tuberculosis ___ Eczema____ Cancer _____Allergies ____ Mental illness _____ Asthma____
Other: __________________________________________________________
BIRTH MOTHER’S PRENATAL HISTORY
Mother's age at child's birth? _____ Mother's health during pregnancy? _________________________
Were any of the following experienced during pregnancy?
Bleeding ____ Physical or emotional trauma ____ High blood pressure____Nausea/Vomiting_____
Cigarettes, alcohol, drug consumption ____ Thyroid problems_____ Illnesses _____ Surgery____
Medications ____ Gestational diabetes____ Depression/Anxiety____ Other_________________
CHILD’S BIRTH HISTORY
Term:
Full
Premature: _____ weeks
Late: _____ weeks Weight at birth:_____lbs, ____ oz.
Length of labor _____________ Any complications?_______________________________________
_________________________________________________________________________________________
Birth:
vaginal
C-section
Induced
Forceps
Suction
Anesthesia used
Did your child have any of the following problems shortly after birth?
Birth abnormality___________________ Birth injuries___________________ Blue baby____ Cerebral
palsy____ Seizures____ Jaundice____ Colic ____ Fever____ Rashes____
Other (explain): ___________________________________________________________________
FEEDING
Breastfed?
yes
no How long? Formula?
yes
no
If Yes:
cow’s milk
soy
other
Child's sleep patterns _______________________________________________________________
How would you describe your child’s temperament?__________________________________________
Food or environmental sensitivities or allergies (if known) _____________________________________
______
________________________________________________________________________________
____
Any dietary restrictions (religious, vegetarian, vegan, etc.)? ___________________________________
Age began solids ______Which foods?___________________________________________________
______
Typical daily diet:
________________________________________________________________
____
________________________________________________________________________________
______
____
Age began: Sitting________ Crawling________ Walking________ Talking________
SYMPTOMS (mark Y if current, P significant past symptom)
Hives
Sleep problems
Easy bruising
Frequent colds
Burning of urine
Acne
Motion/car sickness
Bleeding tendency
Unusual fears
Bloody urine
Anemia
Diarrhea
Eczema
Night sweats
Earaches/Infections
Wheezing
Frequent urination
High fevers
No appetite
Joint pains
Cries easily
Stomach aches
Sore throats
Excessive fatigue
Bleeding gums
Sensitive to light
Constipation
Cough
Heart murmur
Chronic rash
Nightmares
Dizzy spells
Nervous
Jaundice
Headaches
Hair loss
Nose bleeds
Body/breath odor
Gas
Vomiting spells
Hearing loss
Canker sores
Other: ____________________________________________________________________________
Please explain briefly what you would like to see as a result of acupuncture treatments?
____________________________________________________________________________________________
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