Woodlands Healing Research Center

5724 Clymer Rd., Quakertown, PA 18951 * 215-536-1890 * Fax 215-529-9034

 

WELL CHILD HISTORY QUESTIONNAIRE

(Ages: New Born to 12)

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Name of Child:   Date Form Completed:

Gender: Female Male   Date of Birth:      Age:

Attention, Parents or Guardians: As age permits, please have your child participate as much as possible in completing this form. Complete those parts that apply to your child as age allows. Omit the sections that do not apply to you or your child.

This form was completed by (check all that apply):Mother   Father   Child   Other:

MEDICATION ALLERGY AND INTOLERANCE: List any medication or supplement you are allergic to or which caused unpleasant side effects; include the name of the substance, the age it occurred, how it was taken (mouth, vein, etc), what reaction occurred, and the treatment if given. Use additional sheets if necessary.       

Prescription Medication Date Route given Reaction Any Treatment Given
Example: Penicillin    02/2002 By mouth Hives, breathing difficulty None

MEDICATIONS: List medicines, both prescribed by a physician and obtained without a prescription (those that you can buy on your own), that you are currently taking or have taken recently. Complete as much as you are able. Including the name of the medicine, the strength of the medicine (dosage), how often you take it (frequency), date started and date stopped if you are no longer are using it. Please bring all your medication to your appointment. Use the other side of this sheet or additional sheets if necessary.

Medication Dose Frequency (times per day) Started Stopped
Example: Benadryl 25mg 1 pill 2 times per day 1990 ---------

VITAMINS, MINERALS, AND OTHER NUTRITIONAL SUPPLEMENTS:

As above, please list your nutritional supplements to include vitamins, minerals, herbs, homeopathic remedies, folk remedies, and other nutritional or alternative therapies. Please include the form of the supplement (pill/liquid, etc), and the dosage (mg, IU, etc). Please bring all your supplements to your appointment. Use the other side of this sheet or additional sheets if necessary.

Vitamin/Herb/Supplement Dose Frequency (times per day) Started Stopped

Antibiotics: List the number of times you have been on antibiotics such as Penicillin, Tetracycline, Amoxicillin, Keflex, Ceclor, Erythromycin, or other antibiotics: NO   YES, The number of times given antibiotics:

Please check any of the reasons listed as to why  you were prescribed antibiotics, include as many as apply:

Acne/skin condition   Colds    Tonsillitis/Strep Throat    Ear Infection(s)     Bladder/Kidney Infection

Other:

Steroids: Have you ever taken an oral cortisone preparation such as Prednisone, Decadron, Medrol, or others? If yes, state how many times.  NO    YES, The number of times given steroid pills:

Have you received a cortisone type "shot" such a Depo Medrol, Decadron, Kenalog, or others?

 NO   YES, The number of times given steroid injections:

Growth & Development:
Approximate weight (in pounds) at the following ages:    
1 yr: 2 yrs: 3 yrs: 5yrs: 10 yrs:
Approximate age of first tooth:      
List at what age did your child first performed the following; complete those that apply:
Developmental Milestone Age Developmental Milestone Age
1. Lift Head 8. Spoke Clearly
2. Roll Over 9. Bladder trained
3. Sit Up 10. Bowel trained
4. Stand Up 11. Dry @ night
5. Walk 12. Dresses alone
6. Drank from Cup 13. Rode 2 wheel bicycle
7. Knows Name Not sure about the above but everything seemed on schedule
Formal developmental evaluation was done, which revealed:
Puberty Development, list age of : First Menses: Breast development: Pubic Hair:
Are there any difficulties in sexual adjustment/development?

 

PAST MEDICAL HISTORY:  Answer to the best of your ability, any question you don't know, just leave blank.

Preconception History:        

Was the pregnancy: Planned  Planned, with preconception counseling/education  Unplanned
Was the pregnancy: Wanted   Unwanted  
What form of birth control was used prior to conception?
How long before conception was it discontinued? 
In the six months prior to conception was there any:  
Toxic chemical exposure to mother or father, explain:
Poor diet of mother or father, explain:
Medication use (prescription or over the counter) use by mother or father:
Drug or alcohol use by mother or father, explain:
Infections in mother or father, explain:
Stress in mother or father, explain:
Other medical problems, explain:

Was there any thing else that occurred prior to conception that you feel may be important?
   

Prenatal (During Pregnancy) History:

Received OB/Midwife Care   Did not received OB/Midwife Care   
Any problems or complication while mother was pregnant with the child?
High blood pressure Diabetes Venereal disease  Measles or other infection
 Smoke cigarettes Use alcohol/ drugs Caffeine use  
 Child was very active in womb  Child had frequent hiccups while in mother's womb
Mother took medications, explain:
Chemical exposure, explain:
Stress during pregnancy, explain:
Abnormal Ultrasound, explain:
Abnormal test during pregnancy:
Other Pregnancy problem, explain:
Birth History:  
Where were you born? (Hospital, City and State):
Was your delivery:  NL Vaginal Delivery  C-section  Forceps  Vacuum used  Breech
 Pitcoin was used  Antibiotics given in labor  Magnesium Sulfate was given in labor
Complications,explain:
When were you delivered:  Term (near/at due date) Early by  wks  Late by  wks
Child’s Blood Type, if known: A+   A-   B+   B-   AB+   AB-  O+  O-
 Circumcision Done    Circumcision not done
Were there any problems while you were in the hospital nursery?
Was in NICU  Breathing problems  Low oxygen   Needed breathing machine (ventilator)
 Infection   Feeding problem  Blood problems (mismatch, Rh, etc)  Jaundice Needed light therapy
Birth Weight: lbs oz Birth Length: inches APGAR: 1 Min: 5 Min:
Medications given to baby, explain:
Other problems, please explain:
 
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Past Illnesses: Check the disease or conditions that apply to you. Please note whether the problem is now, past or both:
Past Now Birth Defects Past Now Genetic Illness  
Past Now Chicken Pox   Past Now Croup   Past Now Measles
Past Now German Measles Past Now German Measles Past Now Polio 
Past Now Rheumatic Fever  Past Now Scarlet Fever Past Now Whooping Cough
Past Now Mono (EBV) Past Now CMV Virus Past Now Coxsackie Virus
Past Now HIV Virus (AIDS) Past Now Lyme Disease Past Now Meningitis
Past Now Attention Deficit Past Now Hyperactivity Past Now Learning Problem
Past Now Dyslexia Past Now Developmental Delay Past Now Depression
Past Now Tension/Anxiety Problem Past Now Post Traumatic Stress Past Now Physical Abuse
Past Now Sexual Abuse Past Now Anorexia Past Now Bulimia
Past Now Migraine Headache Past Now Epilepsy (Seizures)  
Past Now Nearsighted Past Now Farsighted Past Now Wears Glasses
Past Now Lazy Eye Past Now Blindness  
Past Now Deafness Past Now Wears Hearing Aid Past Now Recurrent Ear Infections
Past Now Hayfever/Allergy Past Now  Recurrent Sinus Infection Past Now Nose Polyps
Past Now Dental Problems Past Now Mouth Ulcers/Sores Past Now Recurrent Tonsillitis
Past Now Congenital Heart Disease Past Now Heart Rhythm Problems Past Now Heart Murmur
Past Now Mitral Valve Prolapse Past Now Other Heart Valve Problem  
Past Now Asthma Past Now Recurrent Bronchitis Past Now Pneumonia