1.) What is the purpose of your visit…what can I do that would help your child the most? ____________________________________________________________________________________________________________________________________________________________________________________________________________ 2.) Please observe your child and provide general answers to the following. Please circle your answer:
In general, are your child’s eyes normally bright Y/N? Is he/she alert and focused or easily agitated? Irritable? Are there dark circles under his/her eyes (not due to lack of sleep)? Y/N? Is the skin plump and smooth or dry, scaly? Are there any rashes, inflammatory issues of the skin, cracks, etc.? If you have any other comments, please list below: ______________________________________________________________________________________________________________________________________________________________________________________________________
3.) Has your child been “diagnosed” with a medical or psychological condition by a specialist, medical doctor, or other doctor?
___________________________________________________________________________________________________
4.) If you answered yes above, what is his/her prognosis?_______________________________________________________ 5.) How often does he/she go to the specialist(s)?______________________________________________________________ Please list specialists, doctors, other contact information (including phone #’s) on a separate page, if required.
6.) If you have you tried any of the following, please list below. Be as specific as possible: Recommended Reaction – positive/negative/no difference…give details SUPPLEMENTS MEDICATIONS DIET CHANGES
HISTORY:
7.) Immunizations (note below, or attach copy of immunization record):
VACCINE AGE REACTIONS
8.) Mother: did you have any immunizations as a teenager, young adult, pregnant or nursing mother? If yes, please list: ________________________________________________________________________________________________ 9.) List any complications during pregnancy, delivery or early weeks of your child’s life that concerned you or your doctor:
_________________________________________________________________________________________________ Gestational age at birth:_______________________
10.) How many ultra-sounds did you have?______________ Did you ever take fertility drugs or CLOMID?________________
2006, by Wellness Wizards Limited, PEDIATRIC INTAKE QUESTIONNAIRE-2 to 12
Name: _______________________________Age: _________D.O.B.: ________________________Today’s Date:______________________ 11.) Did you breastfeed?______For how long?_____ What did you give your child afteror along with the breastmilk?________
___________________________________________________________________________________________________ 12.) How did he/she react to the breastmilk?______, formula?____________, cow’s milk?______________________________ 13.) At which age, and in what order did you introduce solid foods? Provide as many details as you can remember:
__________________________________________________________________________________________________
_________________________________________________________________________________________ ________
14.) Did your child suffer from colic?__________________________________Coping methods: _________________________ 15.) Please circle if any of the following apply… list others if applicable:
Family History of: Multiple Sclerosis, Type I diabetes, Lupus, Rheumatoid Arthritis, Crohn’s Disease, AIDS, Fibromyalgia or Chronic Fatigue Syndrome, neurological problems, mental illness, heart disease, cancer, allergies, diabetes, intestinal diseases or problems. Comments:_______________________________________________________________________ __________________________________________________________________________________________________
16.) Family history of learning disorders, (ADD/ADHD, ASD, PDD, Dyslexia, Down’s Syndrome, Schizophrenia)?__________ 17.) Has your child had any ear infections?______ List how many & age?___________________________________________ 18.) Was the treatment (for ear infections) the same each time, and how did he/she react?
______________________________________________________________________________________________________________________________________________________________________________________________________
19.) Has your child had, or do they presently have any infections or illnesses?________________________________________ 20.) If your child has a re-curing infection of the same type, list social or dietary factors that seem to occur at the same time:
_______________________________________________________________________________________________
DIET & DIGESTION:
Please fill out a DIET DAIRY for 7 days. Record what/how much your child eats & drinks, comments, reactions & moods. Pay particular attention to your child’s reactions to foods (behavior, bowel habits, etc.) while doing this diet diary.
21.) Are there any known food allergies or intolerances?______________________________________________________ 22.) Describe your child’s appetite:_______________________________Number of meals/snacks per day:________________ 23.) Does your child have favourite foods?__________________ How often does he/she eat them?_______________________ 24.) Does your child have cravings?________ If yes, which foods? When is the food consumed?_________________________ 25.) Are there foods your child absolutely refuses to eat?_________________________________________________________ 26.) Are you concerned about your child eating too much? Too little? Developing poor eating habits? Circle if applicable. 27.) Please circle the following if they apply: Difficulties digesting any foods – pain, cramping, screaming, headaches, gas,
bad breath, diarrhea, constipation? Does he/she experience: Alternating diarrhea/constipation, straining to move bowels?
Are any of the above situations related to particular foods or circumstances (such as emotional upset, etc?) ___________________________________________________________________________________________________ ___________________________________________________________________________________________________
28.) Stools – formed, colour?______, foul-smelling, frothy or floating/greasy? Are there pieces of undigested food?___________ Other comments relating to bowel movements: _____________________________________ Number BM/day:__________ 29.) Is your child toilet-trained?_____ Does he/she have accidents? ______Bed-wetting?_______________________________
2006, by Wellness Wizards Limited, PEDIATRIC INTAKE QUESTIONNAIRE-2 to 12
Name: _______________________________Age: _________D.O.B.: ________________________Today’s Date:______________________ DEVELOPMENTAL ASPECTS:
30.) At what age did your child begin to speak?______point?______ 31.) Did you notice that your child began to regress in any of the above, or in other areas, and if so at what age?___________
_________________________________________________________________________________________________
32.) How long is your child’s attention span (approximately?)_____________________________________________________ 33.) Does your child sleep through the night?________________________ Is he/she well/rested?________________________ 34.) Comments from teachers, behavioural therapists, on your child’s progress since diagnosis:__________________________ __________________________________________________________________________________________________ Is your child: aggressive? _____________________Intolerant to heat &/or sunlight?_______________________________ Is your child stressed?________________________Does he/she participate in sports/play groups?___________________ What does he/she like to do for fun?__________________________________________Is he/she happy?______________ How much exercise does your child get?________________ Hours spent watching T.V./video games/day ______________ 35.) How does your child interact in a group environment…with children?___________________________________________ …with other adults?__________________________________________________________________________________ 36.) Is your child generally happy? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 37.) Please list any additional comments, concerns or questions that you may have: ATTACH A SEPARATE SHEET (IF REQUIRED) TO INCLUDE ANY OTHER INFORMATION THAT MAY BE RELEVANT
Your name:____________________________ Address: ________________________________________________________ Relationship to child:_____________________________________________________ Contact information: Daytime:__________________________Evening:_________________E-mail:______________________ Disclaimer: Please note that your personal information will be kept strictly confidential. Please see our privacy policy for further details at: www.wellnesswizards.net. The information and recommendations which you will receive from Wellness Wizards is meant for procuring and attaining health and well-being for your child and not to diagnose, treat or cure any condition. If your child has a serious medical condition, please see your medical health professional. Signature:_____________________________________________________________ Date:____________________________ FAX completed forms to: 905-257-3979 or MAIL to: Wellness Wizards Limited, P.O. Box 478 Dundas St. West, Oakville, ON. L6Y 6Y0 PLEASE NOTE: We cannot guarantee that our office is 100% nut-free. Please notify us ahead of time if you have any severe or life-threatening allergies. We will do our best to accommodate your needs. Please call us at: 416-948-9355 if you have any questions. Thank you for choosing Wellness Wizards.
2006, by Wellness Wizards Limited, PEDIATRIC INTAKE QUESTIONNAIRE-2 to 12
Vitamina D O termo “vitamina D”, usualmente se refere a duas moléculas distintas, a vitamina D2(ergocalciferol)e a vitamina D3(colecalciferol), estruturalmente similares aos hormônios esteroidais clássicos, como o estradiol e o cortisol. A vitamina D é bastante conhecida pela sua função no desenvolvimento e na manutenção do tecido ósseo, bem como pela manutenção da homeostase
SERVICES SURVEY SERIES Introduction The Singapore Department of Statistics conducts an annual survey on the services industries to collect a wide range of data for studies and analyses. The first survey on the services industries was conducted in 1968 for the reference year 1967 and subsequently at regular intervals. Since 1984, the inquiry was carried out on an annual basis. The lates
Name: _______________________________Age: _________D.O.B.: ________________________Today’s Date:______________________