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)

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:
 
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
Past Now Tuberculosis    
Past Now Acid Reflux Stomach Past Now Stomach Ulcer Past Now Lactose Intolerance
Past Now Colitis Past Now Crohn's Disease Past Now Celiac Disease
Past Now Irritable (Spastic) Bowel Past Now Jaundice Past Now Hernia
Past Now Hepatitis A Past Now Hepatitis B Past Now Hepatitis C
Past Now Dysentery Past Now Parasites Past Now Giardia
Past Now Candida Past Now Worms  
Past Now Bladder Infection Past Now Kidney Infection Past Now Urethral Stricture
Past Now Vaginitis (Yeast) Past Now Vaginitis (Other) Past Now Venereal Disease (VD)
Past Now Muscular Dystrophy Past Now Rheumatoid Arthritis Past Now Lupus (SLE)
Past Now Bone Disease Past Now Sciatica Past Now Whiplash
Past Now Eczema Past Now Atopic Dermatitis Past Now Acne
Past Now Psoriasis Past Now Seborrhea Past Now Athletes Foot
Past Now Ringworm    
Past Now Diabetes Past Now Hypoglycemia Past Now Weight Problem
Past Now Hyperthyroidism (High) Past Now Hypothyroidism (Low) Past Now Adrenal Problem

Past Now Blood Disease

 Past Now Anemia Past Now Sickle Cell Disease
Past Now Thalassemia Past Now Hemophilia Past Now Blood Transfusion
Past Now Immune Deficiency Past Now Leukemia Past Now Lymphoma
Past Now Cancer or Tumor    

 

List any other past or present illnesses:
Please list handicaps/disabilities:
If you were ever hospitalized for at least one overnight stay (but did NOT involve surgery or child birth), please describe:

 

OPERATIONS/SURGERIES: Please list your major operations, including same day surgery. List the name of operation, date it occurred, your age, the reason for the operation, name of the hospital, city and state, and any complications (include any anesthesia reactions). Start with early childhood and list in order to the most recent:
Operation Date Age Reason/Complication Hospital
Ex: Tonsillectomy 02/20/1962 5 Recurrent sore throats Shriners

 

INJURIES: List any past injuries you have had (not including those stated in the current problem section). Include the type of injury (car accident, fall, broken bones, machinery/occupation accident, etc), the date it occurred, your age, and any treatment given. Please list from oldest injury to most recent:
Injury Date Age How Injury Occurred Treatment Given
Ex: Neck Sprain 02/20/1962 20 Car Accident Chiropractic
 

HEALTH CARE MAINTENANCE: Please list when you last had the following tests, date, age, location, and the result if known:
Test Date Result
Dental Exam
Hearing Test
Eye Exam/Vision Test
Cholesterol
Tuberculosis (TB) Test

 

IMMUNIZATIONS: Please list the date and age of any immunization or vaccine you have received and any reaction you may have had (you may bring list on separate sheet from another’s physician’s office if available):
Immunization Date Reaction Immunization Date Reaction
DTaP#1 MMR#1
DTaP#2 MMR#2
DTaP#3 PCV (Pneumococcal)#1
DTaP#4 PCV (Pneumococcal)#2
DTaP#5 PCV (Pneumococcal)#3
TetanusBooster (DT) PCV (Pneumococcal)#4
Hib (H.flu)#1 Chickenpox#1
Hib (H.flu)#2 Chickenpox#2
Hib (H.flu)#3 Meningococcal
Hib (H.flu)#4 Last Flu shot
Hepatitis B#1

Others:
Hepatitis B#2
Hepatitis B#3
Polio#1
Polio#2
Polio#3
Polio#4

 

FAMILY HISTORY: Family background may be related to medical conditions. Please fill in all of the following chart to the best of your ability, you may wish to call certain relatives for information if needed. State their first name, mark if the they are deceased (X), the age they died, their ethnic background (of your grandparents and parents), cause of death and lastly any medical conditions or illnesses they have had or currently have. You may wish to refer to the list of medical illnesses on page 3 to see if any apply to your family history. Be sure to include genetic or birth defects, mental retardation, or any other unusual disease. You should also include other family members with significant medical history, (Ex. maternal aunt with breast cancer). Circle all those who live with you now.
Family Member Name Deceased Age Ethnic Cause of Death Illnesses
Example Bill

X

 72 Hispanic Heart Attack Diabetes, High Cholesterol, Prostate Cancer
Mother's Mother
Mother's Father
Natural Mother
Father's Mother
Father's Father
Natural Father
Brother's & Sisters: start with the oldest and include yourself, place a * next to your name. Do not list your illnesses, jus those of your family members

 

Others:

 

SOCIAL HISTORY:
Second Hand Smoke:   No exposure Child is exposed to second hand smoke, where?:
Education/School: Public School Private School Home Schooled
What grade is your child currently in or just completed? At what age did your child start school?
How well do you feel your child does in school? Very Well Well Fair Poorly Does not apply
How well does your child like school?   Very Well Well Fair Poorly Does not apply
How well satisfied are you with the school?  Very Well Well Fair Poorly Does not apply
Any problems your child has at school, explain:
Religious Affiliation/Denomination:
Home Life: Are there any problems at home that concern you? Please explain:
Discipline: The following types of discipline are used to change this child’s behavior (check all that apply):
Time out Remove/limit favorite activity Use bribes
Spanking with hand Spanking with paddle, belt or other object Yell and scream
Other:
How many times in a day do you say “No” or “bad” to this child?
How many times in a day do you say “yes”, “good” or “well done” to this child?
Are there any questions or concerns you have about your child’s behavior or your methods of discipline?
Hobbies/Play Activities & Exercise:
How well does he/she get along with friends? Very Well Well Fair Poorly Does not apply
How well does your child play with others? Very Well Well Fair Poorly Does not apply
How well satisfied are you with the school?  Very Well Well Fair Poorly Does not apply

Does he/she belong to any organizations

(ie, Boy Scouts/Girl Scouts, church group, band) etc:
If he/she likes books and/or movies, what are the favorites?
Who is your child’s favorite TV, book or movie character?
Is there interest or skill in artistic activities?
Any sports involvement?
Other exercise programs:
Personal Habits:    
How much time do you spend watching TV each day? Hours Reading each day? Hrs
How often do you brush your teeth? Times/day Floss your teeth? Times/day
DIET:    
Infancy: Failure to gain weight Gained too much weight
Breast fed, until age: Had problems with weaning, explain:
Bottle fed from age:  to age: Type of formula: Milk based Soy Hypo-allergic
Had to switch formulas  Which types: Milk based Soy Hypo-allergic Other:
Age solid food was started: Months old
List any foods omitted from the diet during early infancy and why:
Other feeding problems, explain:
Current Usual Diet: There are feeding difficulties or problems, explain:
Water: Glasses per day consumed:    
Type of water consumed: Tap Distilled Spring Well  
Bottled in plastic Bottled in glass Fluoridated Filtered  
How meals per week are the following foods consumed?
White bread/rolls/bagels: Milk: Diet Soda:
Whole grains: Cheese: Soda
Chocolate: Ice Cream: Cups hot chocolate:
Candy: Vegetables: Cups tea with caffeine:
Fast food meals: Salty foods: Cups tea without caffeine
What type of sweetener is used:      
White sugar Artificial Sweetener Honey Molasses Stevia Other:
What type of cooking oil is used:      
Vegetable oil Canola Oil Olive Oil Lard Crisco Pam Other:
Do you use: Margarine Butter      
Types of fruits and vegetables eaten?      
Fresh Frozen Canned Organic without insecticides