Personal Information - Please Print Clearly

Daniel Brousseau, D.O. • Simon Barker, N.D. • Nadia Mistry, N.D. CHILD INTAKE PERSONAL INFORMATION - PLEASE PRINT CLEARLY

PATIENT'S NAME:______TODAY'S DATE: ______PATIENT'S DOB: M______D______Y______PATIENT'S AGE: ______

PARENT/GUARDIAN PARENT/GUARDIAN NAME:______NAME:______EMAIL:______EMAIL:______ADDRESS______ADDRESS______STREET STREET ______CITY ZIP CITY ZIP BEST PHONE # ______hm off cell  BEST PHONE # ______hm off cell  Voicemail OK? YN Voicemail OK? OCCUPATION (previous if retired) ______YN EMPLOYER______OCCUPATION (previous if retired) ______EMPLOYER______

HOW DID YOU HEAR ABOUT US? Please specify: ______

740 N. Lake Avenue • Pasadena, CA 91104 112 E. Olive Avenue, Suite E • Redlands, CA 92373 tel: (626) 794-4668 • fax: (626) 345-9753 tel: (909) 793-4477 • fax: (909) 793-9350 email: [email protected] email: [email protected] web: pasadenanaturalhealth.com web: redlandsnaturalhealth.com

PLEASE LIST YOUR CHILD’S HEALTH CONCERNS (if any): 1. ______4. ______2. ______5. ______

MEDICAL HISTORY - Please check any of the following that apply and note when they started _____ AIDS/HIV Infection _____ Frequent Antibiotic Use _____ Measles _____ Allergies _____ Frequent High Fevers (>102°F) _____ Mononucleosis _____ Anemia _____ Frequent Steroid Use _____ Mumps _____ Appendicitis _____ Genetic Disorder _____ Neurological Disorder _____ Arthritis _____ German Measles _____ Poor concentration _____ Asthma _____ Hayfever _____ Psoriasis _____ Awkwardness _____ Headaches _____ Restlessness _____ Birth Defects _____ Heart Murmur _____ Rheumatic Fever _____ Bladder/Urinary Tract Infections _____ Hepatitis _____ Scarlet Fever/Scarlatina _____ Cancer _____ Herpes/Cold Sores _____ Seizure Disorder _____ Chickenpox _____ Hypoglycemia _____ Social immaturity _____ Chronic Ear Infections _____ Impulsiveness _____ Talkativeness _____ Colitis/Crohn’s Disease _____ Inactivity _____ Tantrums _____ Depression _____ Inconsistency _____ Thumb Sucking _____ Developmental Delay _____ Irritability Until what age? ______Diabetes _____ Jaundice _____ Tuberculosis (TB) _____ Distractibility _____ Kidney Infections _____ Tubes in ears _____ Eating Disorder _____ Left/Right Confusion _____ Whooping Cough _____ Eczema _____ Listlessness _____ Exposure to Toxic Substances _____ Lyme Disease Other: ______

Review of Systems Please indicate the following N= a condition you have NOW P= a condition you have had in the PAST

Skin Mouth Dry ______Dryness___ Excessive Salivation___ Oily ______Tongue: Sore___ Coated___ Itching ______Canker Sores ______Rashes ______Hives ______Respiratory Fungal Infections ______Pneumonia ______Bruises Easily ______Bronchitis ______Slow Healing ______Cough ______Warts _____ Moles_____ Spit up Blood ______Where ______Asthma ____ Wheezing_____ How Many ______Shortness of Breath ______Nails Soft_____ Break_____ Positive TB Test Ever ______

Head Cardiovascular Migraines_____ Headaches_____ Heart Palpitations/Racing ______Location of pain______Heart Defect ______Worse: Light __ Noise__ Odors__ Murmur ______Head Injury ______High___ Low___ Blood Pressure Describe______Leg Pains ____ Cramps____ Dizziness ______Ankle Swelling ______Fainting ______Cold Hands_____ Feet_____ Seizures ______Digestion Eyes Bowel Movement ______Vision Disturbance ______X per day: 1-2___ 2-3___ 3-4___ or Dryness_____ Tearing_____ X per week: 1-2___ 2-3___ 3-4___ Pain ______Texture: Dry___ Hard___ Styes ______Wet/Loose___ Pellets___ Infections ______Stools with Mucous___ Blood____ Sensitive to Light ______Hemorrhoids Bleeding___ Painful___ Itching___ Ears Fissures/Fistulas ______Discharge ______Stool Incontinence ______Pain_____ Itch_____ Very dark stools ______Tubes inserted ______Very light stools ______Impaired Hearing ______Bowel Disease ______Ringing ______Liver/Gallbladder Disease ______Ulcer ______Nose Heartburn ______Seasonal Allergies ______Bloating ______Drainage ______Belching ______Color: Clear___ Yellow___ Green___ Gas / Flatus ______Texture: Runny_____ Thick_____ Nausea / Vomiting ______Post Nasal Drip ______Pains / Cramps ______Stuffiness ______Sneezing ______Urinary Sinus Infections ______Difficult Urination ______Nosebleeds ______Painful Urination ______Incontinence/Dribbling ______Throat/Neck Blood in Urine ______Pain in Throat ______Frequent Urination Day ______Glands Enlarged ______Night ______Difficult Swallowing ______Frequent Bladder Infections ______Change in Voice ______Bedwetting ______Clears Throat Often ______Sleep Perspiration Muscular/Skeletal Good____ Bad____ Sweat Easily Y / N Back Pain ______Wake Easily? Y / N Sweat Excessively Y / N Pain in Muscles/Joints/Bones ______Why?______Sweat Very Little Y / N Stiffness/Swelling ______Frequently? Muscle Weakness/Tremor ______Difficulty Falling Asleep Y / N Appetite Numbness/Tingling ______Wake Refreshed Y / N Excessive____ Good____ Poor____ Shooting Pain ______Snore Y / N Talk Y / N Foods child craves strongly______Paralysis ______Grind Teeth Y / N Sleep Walk Y / N ______Any Side Worse: R___ L___ Preferred Sleeping Position______Foods child dislikes strongly______Ever Broken Bones? Nightmares Y / N ______Which______Prefers foods Hot__ Warm__ Cold__ Ever Sprained Joints? Temperature Thirst: Excessive __ Good__ Poor__ Which______Sensitive to: Hot__ Cold__ Both___ Prefer drinks: Very Hot___ Hot___ Prefer: Inside___ Outside___ Warm__ Cold__ Ice cold__ GENERAL Warm blooded___ Cold blooded___ Recent Weight Change Y / N Energy (scale of 1-10) Best Season___ Worst Season___ 1=worst 10=best ______Best Time of day___ Worst Time ___

Pregnancy Vaccination _____ Nausea _____ Fully vaccinated _____ Threatened miscarriage _____ Partially vaccinated _____ High blood pressure _____ Please specify ______Preeclampsia ______Back pain _____ Not vaccinated _____ Any unusual vaccines _____ Birth (e.g. yellow fever, Lyme, smallpox) _____ Vaccine reaction _____ Induction (pitocin) _____ Long or difficult labor or delivery _____ Please explain: ______Prematurity _____ Child late _____ Cord around neck _____ Breech delivery _____ Caesarian section with prior labor _____ Scheduled caesarian _____ Rapid delivery _____ Drugs during labor _____ Please list ______

Neonatal

Rh incompatibility _____ Jaundice _____ Long time to produce breathing _____ Weight at birth _____ Height at birth _____ Colic _____ Much crying for no reason _____ Failure to thrive _____ Breast fed _____ How long? ______Difficulties with nursing? ______

Development

Periods of separation from mother _____ If so, when? _____ How long? ______Difficulties learning to walk _____ Difficulties learning to speak _____ Past History Depression Hospitalization(s): ______Diabetes ______Eczema ______Epilepsy Headaches Serious Illnesses and Injuries: ______Heart Attack ______Heart Disease ______Hepatitis High Blood Date of Last Physical______Pressure Date of Last Blood Tests______High Cholesterol Kidney Disease Personal Family History: Mental Illness Please check the “yes” box next to each condition that applies Osteoporosis to the child or one of his/her family members. Please note whether the condition applies to the patient by writing the Stroke word “child” in the relation column. If the condition applies Suicide to a family member, please write the relationship to her/him in Thyroid Disease the relation column (e.g. mother, aunt, sister, father) Tuberculosis Other CONDITION YES RELATION PAST (P) / NOW (N) Alcoholism/Drug Addiction Allergies Alzheimer’s Anemia Arthritis Asthma Cancer Type? Please list the names of your child's health care providers: ______

Please describe your child's living situation (e.g. divorced parents with joint custody) and any tension at home ______

Please list all prescription and over the counter medications that s/he is currently taking:

Medication Dose Date Started Prescribed By

List vitamins, minerals, herbs, homeopathic remedies that s/he is currently taking:

Supplement Dose Date Started Please list any severe or life-threatening allergies that your child has: ______

Please Explain______

Personal Habits hours/week hours/week (present) (past) how much? how long for? Television Soda Does Computer/Video Games Sweets/Candy the Video/Movies Coffee/Tea child have any dietary restrictions or follow a particular dietary regimen? If yes, please describe: ______Does s/he exercise regularly? Yes No What type? ______