Tree of Life Health Solutions Pediatric Health Questionnaire

Patient Name:__________________________________________ Date: _________________ 
Child’s BirthDate: _________________             qBoy or qGirl
Birthplace: Hospital/City/State: _________________________________________________
Pregnancy:
 Duration of pregnancy: ______ weeks
Were there any illnesses or complications, and if so, during what month of pregnancy?
______________________________________________________________________________
Delivery:  Birth weight: _________ Length: __________
Any difficulties at the time of delivery? ______________________________________________   
In the nursery and the first 4 weeks, were there:  Breathing problems? _____                          Fever? _____ Convulsions? _____ Was there yellow jaundice requiring treatment?____
Family Background:
Child lives with:  qBoth parents;  qMother only;  qFather;  qOther relative or guardian
Please markif yourchild’s blood relatives have ever had any of the following conditions.
Anemia (Sickle Cell, Mediterranean, etc.)_____ Bleeding disorders (Hemophilia)_____
Thyroid disease (Goiter, Nodule) _____   Diabetes _____  High blood pressure _____
Rheumatic fever or Rheumatic heartHeart attack before age 55_____
Cystic Fibrosis _____  Allergies (Eczema, Hay fever, Hives) _____
Seizures (Epilepsy)_____     Alcoholism or drug abuse ______ 
Cancer or Leukemia ______ Sudden or unexplained death _____  SIDS _____  
Other ____________________________________________________________________________

Nutrition: 
During Infancy:  Breast/bottle fed?_____________________ Duration:_________Months
Was the baby allergic or intolerant of any foods?qYes or qNo,if YES, which foods? _____________________________________________________________________________
During Childhood: How was diet?_____________________________________________________________________________
Any dietaryconcerns?_____________________________________________________________________________
During Adolescence:History of skipping meals/purging/restricting behavior?qYes or qNo, if YES Explain:______________________________________________________________________________
Growth and Development:Development: Any history of developmental delay in your child? qYes or qNo, if YES, Describe:______________________________________________________________________________
Growth: Any concerns about  your child’s growth or failure to thrive? qYes  or qNo,  if  YES Describe:______________________________________________________________________________
Indicate the age(s) at which your child might have had any of the following: Mumps_________Chickenpox_________Whooping Cough_________                                    Rheumatic Fever_________Asthma_________Anemia_________Convulsions_________       Heart Disease_________Pneumonia_________Hepatitis (Jaundice) _________                     Regular (Red, Hard) Measles_________Scarlet Fever_________                                               Kidney/Urinarydisease_________  Rubella/German/3 day measles __________                                                                              Constipation_________Hearing loss_________  Vision Problems_________Eczema_________
Has the child ever been seriously injured?  qYes or qNo, Age: _____  Injury: ______________
Has the child had tonsils or adenoids removed?  qYes or qNo, Age: ________
Has the child ever had a blood transfusion? _______
List other serious illnesses/hospitalizations/or surgeries (description & date) _____________________________________________________________________________

Is your child regularly taking any medications/supplements?  qYes or qNo, Whichones?___________________________________________________________________________________________________________________________________________________________
Is your child allergic to any medicines/foods, etc.qYes or qNo, if YES please list/circle below along with reaction (rash, vomiting, diarrhea, etc): ____________________________________________________________________________________________________________________________________________________________
Are there behavior problems at home?qYes or qNo, if YES, please describe:____________________________________________________________________________________________________________________________________________________________
Is  there  any  history  of  learning  difficulties/disabilities  or  problems  at  school?qYes  or qNo,       Describe:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are  there  any concerns you would like to discuss with the doctor today?qYes  or qNo,Describe:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date:__________________ Signature: _________________________________________________
Printed Name of Above: ____________________________________________________________