Keweenaw Holistic Family Medicine Pediatric Intake Form
Parents marital status (circle): Married / Separated / Living Together / Other:Current Grade in School:
Please indicate the severity of your symptoms by checking the box that applies to each symptom (sx). Part I: ENT - Allergy Symptoms Mild Moderate Severe Moderate Severe Moderate No Sx Mild Sx No Sx Mild Sx Severe Sx Nose Symptoms Chest Symptoms Nervous System Skin Symptoms Throat Symptoms Urinary System Ear Symptoms Gastrointestinal Miscellaneous Eye symptoms
Keweenaw Holistic Family Medicine Pediatric Intake Form
Part I: ENT - Allergy Symptoms, Continued
Has Pt taken antibiotics for acne for 1 month or
Includes: tetracycline (Doxycycline, Minocin) and
Has Pt taken "broad spectrum" antibiotics for
infections (respiratory, urinary, or other) for 2 months
Includes: Keflex, Ampicillin, Amoxicillin, Ceclor,
Bactrim, Septra, Ceftin, Cefzil, cipro, Levaquin, Avelox, Tequin, Zithromax, Ketek and more
Has Pt ever taken a "broad spectrum" antibiotic, even
Includes most intravenous (IV) antibiotics
Has Pt used oral or injected steroid drugs (Cortisone,
Prednisone, Medrol, Decadron) even one time?
Keweenaw Holistic Family Medicine Pediatric Intake Form
Moderate Severe Moderate Severe No Sx Mild Sx Moderate Sx Symptoms, "Major" Symptoms "Minor" Symptoms "Minor" Cont.
List any foods child dislikes or foods that disagree with child:
Keweenaw Holistic Family Medicine Pediatric Intake Form
Yes / No What kind? _______________________________
Yes / No Hours/Night? _____________________________
How many hours of sleep per night does child get?
…Fall asleep easily (w/in 5 min)?… Wake to urinate?… Wake at other time(s)?… Snore?
On a scale of 1-10, with 10 being the most energy and most stressful, where would you rate your child's:
Birth History
Among the children in the family, child ranks: (circle) Oldest / Middle /
What was mother's state of mind during child's
Mother's health during child's pregnancy: (circle all that apply) Healthy -
pregnancy? (circle all that apply) Happy / Angry /
Diabetes - Hypertension - Smoking - Caffeine - Alcohol - Nausea/Vomiting -
Alcohol - Recreational Drugs - Emotional Stress
Were child's developmental milestones (talking, walking):
How was mother's relationship with father during child's pregnancy? Good / Strained / Bad / None at all
Vaginal or Cesarian birth (circle). Number of weeks at delivery:
Labor was Spontaneous or Induced (circle). If induced, please explain:Labor was in a hospital or other (circle). If other, please describe:Number of hours of labor:
Pre-School Age School Age: Elementary
When Pt started going to school, how did he/she like it?
During Pt's pre-school years, how did Pt's parents relate to each other?
As a small child, did Pt need medical When Pt remembers pre-school years, does treatment for:
Keweenaw Holistic Family Medicine Pediatric Intake Form
School Age: Elem, continued…
Did Pt have any injuries or operations while
Is Pt "hyperactive" or been given drugs for
Did Pt's behavior or relations with teachers and
friends suffer in Middle school? (circle)
Did Pt's grades change in Middle/ Jr. High school? (circle)
While in high school, did Pt have problems with: (circle)
Relations with classmates / Run-ins with the Law / Alcohol or
drug use / Health problems / Operation or injury
During Pt's childhood and through high school, has Pt been bereaved
Activity and exercise during school years: (check a box with your estimate)
During any time in Pt's childhood or teen years, has Pt suffered from
Has Pt suffered from other stressful events at any time in their life that have not been covered here? You may use this space to note them. Go to the back side of this paper if you need to write more. Thank you!
Any problems with menstrual cycle? (cramps, pain, heavy flow, mood swings, etc) Please list.
Any difficulty tolerating Has Pt's cycles or the pattern of her menstrual flow changed
Keweenaw Holistic Family Medicine Pediatric Intake Form
When you have completed this long, long questionnaire, I will have a pretty good idea about your/your child's health problems. Yet, I need your help in setting our goals.
Your top three health goals. If, given the opportunity to cure/fix your health problems… What are your three biggest health problems to be wished away? Please be clear and specific.
One last question: How many doctors have you seen about these problems? ___________________
This completes the packet of questions we will review at your first visit to the office. Please use the space below or on the back of this page to note questions and comments that you wish to discuss at your visit with me. Thank you for your hard work and all the time you spent completing this!
GETTING READY FOR NASAL SURGERY What to expect - You can expect to have visible bruising and swelling for several weeks. You can expect to have drainage for a few days. 6 WEEKS BEFORE SURGERY Your surgeon may request abstinence from smoking and all tobacco products 6 weeks before and 6 weeks afterward. Failure to abstain from tobacco may result in your surgery being postponed or canceled
ANGOR INESTABLE ó DE PRINZMETAL Aparece durante el reposo, muy frecuentemente en el momento del sueño. El paciente refiere opresión o dolor retroesternal progresivamente intenso acompañado de palidez, diaforesis, angustia y usualmente tiene una duración de 5 a 10 minutos, aunque puede llegar a durar 30 o más minutos. Se origina por espasmo coronario y característicamente el ECG tomado