Chico Naturopathic Medicine
1351 Esplanade Chico, CA 95926
530.332.9355 (WELL)
PEDIATRIC HEALTH HISTORY
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Patient name (last, first)
Is patient currently receiving healthcare? Y N
If yes, where and from whom?________________________________________________________
If no, when and where was medical or health care last received?
_________________________________________________________________________________
What was the reason?_______________________________________________________________
What are the most important health problems? List as many as possible in order of importance.
1._______________________________________________________________________________
2._______________________________________________________________________________
3._______________________________________________________________________________
4._______________________________________________________________________________
5._______________________________________________________________________________
6._______________________________________________________________________________
Does patient have any known contagious diseases at this time? Y N
If yes, what?______________________________________________________________________
CURRENT MEDICATIONS
Please list any prescription or over-the-counter medications patient is taking, with dosages.
1.___________________________________ 3._________________________________________
2.___________________________________ 4._________________________________________
Please list any vitamins or other supplements patient is taking, with dosages.
1.___________________________________ 3._________________________________________
2.___________________________________ 4._________________________________________
ALLERGIES
Is patient hypersensitive or allergic to…
Any drugs?_______________________________________________________________________
Any foods?_______________________________________________________________________
Any environmental?________________________________________________________________
HOSPITALIZATION AND SURGERY
What hospitalizations or surgeries has the patient had?
____________________________year:______ ________________________________year:______
____________________________year:______ ________________________________year:______
X-RAYS AND SPECIAL STUDIES
X-rays, CAT scans, or other studies patient has had:
_________________________________________________________________________________
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IMMUNIZATIONS
Polio
Y N
Pertussis
Tetanus shot
Y N
Diptheria
Measles/Mumps/Rubella
Y N
Hepatitis B
HIB
Y N
Influenza
Any adverse reactions to immunizations? Please specify.
Y
Y
Y
Y
N
N
N
N
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FAMILY HISTORY
Father Mother Sisters
Age (if living)
_______ _______ _______
Health (G =good P = poor) _______ _______ _______
Age at death
_______ _______ _______
Brothers
_______
_______
_______
Check applicable:
Cancer
Diabetes
Heart Disease
High Blood Pressure
Autoimmune Disease
Epilepsy
Mental Illness
Asthma/Hayfever/Hives
Anemia
Kidney Disease
Eczema
Tuberculosis
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MEDICAL HISTORY
Please check those that are applicable.
Asthma_____
Bronchitis_____
Chicken Pox _____
Croup_____
Diphtheria
_____
Eczema
_____
Frequent Colds _____
Measles
_____
Mumps_____
Pneumonia_____
Rheumatic Fever_____
Scarlet Fever_____
Tonsillitis_____
Other_______________
Any known exposure to heavy metals (mercury or lead paint) or toxins (pesticides or asbestos)?
_______________________________________________________________________________
Weight:___________ lbs.
Height: ___________
Weight 1 year ago: ___________lbs.
BIRTH HISTORY
Born at how many weeks gestation? _____ weeks
Length of labor __________ Weight at birth __________
Complications, if any _____________________________________________________________
Previous pregnancies by biological mother _____ live births _____ miscarriages
Mother’s age at child’s birth _____
Mother’s health during pregnancy (please mark all that apply):
Amalgam removal or fish intake_____ Diabetes_____
Bleeding_____
High blood pressure_____
Chemical exposure_____
Physical or emotional trauma_____
Cigarette, alcohol or drug use_____
Thyroid imbalance_____
Other health concerns______________________________________________________________
As a baby, did the patient have any of the following?
Allergies_____
Blue baby_____
Diarrhea_____
Birth defects_____ Cerebral palsy_____ Fever_____
Birth injuries_____ Colic_____
Jaundice_____
Rashes_____
Seizures_____
Other_____
Feeding: Breast fed _____ how long? _____ months/years
Formula: milk or soy
Age began: Sitting _____ months
Crawling _____months
Walking _____ months
First: Tooth _____months
Solid foods _____ months
Words _____months
SYMPTOMS
Please circle: Y = a condition patient has now, N = never had, P = has had in past
Dizzy spells Y N P
Nose bleeds Y N P
Cries easily Y N P
Heart murmur Y N P
Body/breath odor Y N P
Nervous Y N P
Hair loss Y N P
Constipation Y N P
Nightmares Y N P
Night sweats Y N P
Diarrhea Y N P
Unusual fears Y N P
Headaches Y N P
Gas Y N P
Bone/joint pain Y N P
Hearing loss Y N P
No appetite Y N P
Flat feet Y N P
Sore throats Y N P
Stomach aches Y N P
Acne Y N P
SYMPTOMS CONTINUED…
Sensitive to light Y N P
Vomiting spells Y N P
Chronic rash Y N P
Motion/car sickness Y N P
Canker sores Y N P
Eczema Y N P
Sleep problems Y N P
Excessive fatigue Y N P
Hives Y N P
Anemia Y N P
Frequent colds Y N P
Bloody urine Y N P
Bleeding gums Y N P
High Fever Y N P
Burning of urine Y N P
Bleeding tendency Y N P
Cough Y N P
Frequent urination Y N P
Easy bruising Y N P
Wheezing Y N P
Other Y N P
DIETARY
Typical Food Intake
Breakfast: ________________________________________________________________________
Lunch: __________________________________________________________________________
Dinner: __________________________________________________________________________
Snacks: __________________________________________________________________________
To drink:_________________________________________________________________________
Refined sugar? Y N
Fast food? Y N
Food with artificial colors or preservatives? Y N
Artificial sweeteners? Y N
Number of servings per week?
Fish ________
Red Meat ________
Chicken________
Number of servings per day?
Vegetables ________
Fruit________
Water________
Please write any additional information:
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