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Pediatric Patient Form

    PATIENT INFORMATION

    Sex femalemale

    IN CASE OF EMERGENCY, CONTACT

    HOW CAN WE HELP YOUR CHILD?

    Wellness CheckupOther
    Has your child been treated on an emergency basis? NoYes

    PREGNANCY HISTORY

    Did you experience any complications during your pregnancy? (check all that apply)
    Back/Other PainGestational DiabetesPre/EclampsiaPre-TermStrep BFatigueSwellingNauseau/Vomitting

    BIRTH HISTORY

    Type of birth (check all that apply)
    HomeEpiduralNormal / VaginalBreechHospitalBirth CentreCaesareanScheduled/Induced

    JaundiceMeconiumAntibioticsRespiratory DistressCongenital AnomaliesExtended HospitalizationFailure to Thrive

    GROWTH & DEVELOPMENT

    Infant Feeding BreastBottleFormula
    At what age did the child:

    CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

    Has your child ever suffered from (check all that apply)?:
    AllergiesAnaemiaAsthmaArm ProblemsBack AchesBed WettingBroken BonesBehavioural ProblemsChronic Ear AchesColds/FluColicConvulsions/SeizuresDelayed SpeechDiabetesDizzinessDigestive Issues (constipation/diarrhoea)FaintingHeadachesHeart TroubleHyperactivityHypertensionJoint ProblemsJuvenile Rheumatoid ArthritisLeg ProblemsNeck ProblemsNeuritisOrthopaedic ProblemsParalysisPoor AppetiteRuptures/HerniasSinus TroubleTuberculosisWalking Problems
    Have you vaccinated your child?
    NoYesAs scheduledDelayed Schedule

    ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY

     

    SIBLINGS

    Are you currently pregnant? NoYes