Integrative Pediatrics of Olney
HISTORY
Birth History
Name: _______________________________Birth Date: ____________Time:___________________
Birth Wt.: ______________Length:_______________Head circumference: _____________________
Number of week’s (of Pregnancy):______________Type of Delivery: _________________________
Any problems during labor or delivery: __________________________________________________
Any issues during Nursery the stay: ____________________________________________________
Jaundice (Y / N) -If YES; Rx: ___________________Discharge weight (on date):________________
Vaccines given (Date):________Hearing screen (Date): ________Newborn screening (Date) _______
Breast/ Formula: _____________Feeding Problems: ___________________Colic:_______________
Mother's Pregnancy History
Age: _________Name of Obstetrician: _________________________ Mom's Blood Type__________
Anemia: ________________Antibiotic use: ______________________________________________
BP: _____________Gestational diabetes: ______________Emergencies:______________________
Preterm labor (# of weeks of Gestation, Treatment given, How long):__________________________
Surgery: ________________Smoking:__________________Hep B Status (neg/pos):_____________
Alcohol: ______________Drugs:_________________Second Hand Smoke: ___________________
Vaccinations: _______________________HPV / HERPES (Y/N) - if Yes, Rx: ____________________
Any other problems during Pregnancy OR Labor: _________________________________________
Prenatal Vitamins: ____________________Other supplements taken: _________________________
Child's Milestones (Approximate Age in months)
Motor
Head steady:_________________Rolled over:__________________Sat up:___________________
Sat up without support:_____________Crawled:_____________Stood with support:_____________
Walked:______________________________Pointing:_____________________________________
Verbalization
Cooing:_________Blabbering:_________Single word/s:________2-3 word Phrases:_____________
Toilet Trained:_____________________________________________________________________
Does your child have problems with?
Sleep:________________Nightmares:____________________Bed Wetting:___________________
Nail Biting:_________________ Anger:____________________Anxiety:______________________
Patient Name:
Medical History
ALLERGIES: Environmental:______________________Food /s:____________________________
Age at Diagnosis:_____________Medications:_________________ER visits: __________________
ASTHMA:______________Age at Diagnosis:_________Medications:_________________________
Admission to Hospital:__________________ER visit/s( with Dates):__________________________
Pulmonologist (Name & Hospital):_____________________________________________________
ADD/ ADHD:________Age at Diagnosis:________Medication/s:_____________________________
Why medicine stopped or changed:____________________________________________________
SPEECH Problems: __________ Age at Diagnosis:__________Speech therapy:________________
HEARING Problems: __________________Treatment:____________________________________
VISION Problems: ___________________Treatment:______________________________________
INJURIES/FRACTURES:__________Which Part:________Age:______Treatment/ surgery:________
DIET:____________________________________________________________________________
Vitamins/ Supplements taken regularly: _________________________________________________
_________________________________________________________________________________
SURGERIES (Date/ Age) ____________________________________________________________:
IMMUNIZATIONS (Up TO Date/ NOT):_________Which one/s Missing or Pending:______________
Exposure to SECOND HANDSMOKE:_________________________________________________
PETS at home:____________________________________________________________________
DAYCARE/ BABYSITTER:__________________First Started:____________Hours/week:________
DENTIST: ________________________________________________________________________
Last Visit:___________Any Problems:__________________________________________________
SCHOOL:________________________________________________Grade:__________________
EXERCISE/ SPORT:_______________________________________________________________
ALLERGY TO MEDICATIONS: ________________________________________________________
REACTION/MANIFESTATION: ________________________________________________________
SIBLINGS:
#
1
2
3
Name
Age/ DOB
Medical
History
Intervention
4
Patient Name:
Family History
Condition
Asthma
Allergies
ADD/
ADHD
Heart Disease
Behavioral
Problems/
Depression
High
Cholesterol/
Heart Attack
High Blood
Pressure
Cancer (which
organ)
Diabetes
Kidney Disease
Language
Deficits
Rheumatoid
Arthritis or
Lupus
Surgery
Thyroid
Problems
Vision Deficit
Smoking
Alcohol
Drugs
STD's/ HIV
Hep B/ Hep C
Hearing/
Speech Deficits
Age
Mother
MGM
MGF
Father
PGM
PGF
Patient Name:
Mother's Siblings
Significant
History
Age at Diagnosis
Intervention
1
2
3
4
Father's Siblings
Significant History
Age at Diagnosis
Intervention
1
2
3
4
Developmental Delay in any (Extended) Family member:
Diagnosis:________________Age at Diagnosis:_________Current Treatment:_________________
DECLARATION
I, ___________________________________(Mother/Father), certify that the information that I have
supplied is correct and accurate to the best of my knowledge.
SIGNATURE: _____________________________________________________________________
DATE: ___________________________________________________________________________