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ALLERGIESMedication/Supplement/Food Reaction

COMPLAINTS/CONCERNS

MEDICALHISTORY

Functional and Integrative Medicine of McCall

PEDIATRICMEDICALASSESSMENT

Name: Date: DOB: Whatdoyouhopetoachieveforyourchildinyourvisitwithus? Ifyouhadamagicwandandcoulderasethreeproblems,whatwouldtheybe?1. 2. 3. Whenwasthelasttimeyourchildfeltwell? Didsomethingtriggeryourchild’schangeinhealth? Isthereanythingthatmakesyourchildfeelworse? Isthereanythingthatmakesyourchildfeelbetter? Pleaselistcurrentandongoingproblemsinorderofpriority:

Severity Success

DescribeProblem Mild

Moderate

Severe

PriorTreatment/Approach Excellent

Good

Fair

Example:PostNasalDrip X EliminationDiet X þ=PastConditionþ=OngoingCondition

2

MEDICALHISTORY(cont…)

DISEASES/DIAGNOSIS/CONDITIONSCheckappropriateboxandprovidedateofonset

GASTROINTESTINAL☐☐IrritableBowelSyndrome ☐☐InflammatoryBowelDisease ☐☐Crohn’s ☐☐UlcerativeColitis ☐☐GastritisorPepticUlcerDisease ☐☐GERD(reflux) ☐☐CeliacDisease ☐☐Other

CARDIOVASCULAR

☐☐HeartDisease ☐☐ElevatedCholesterol ☐☐Arrhythmia(irregularheartrate) ☐☐Hypertension(highbloodpressure) ☐☐RheumaticFever ☐☐MitralValveProlapse ☐☐Other

METABOLIC/ENDOCRINE☐☐Type1Diabetes ☐☐Type2Diabetes ☐☐Hypoglycemia ☐☐MetabolicSyndrome (InsulinResistanceorPre-Diabetes)☐☐Hypothyroidism(lowthyroid) ☐☐Hyperthyroidism(overactivethyroid) ☐☐EndocrineProblems ☐☐WeightGain ☐☐WeightLoss ☐☐FrequentWeightFluctuations ☐☐Bulimia ☐☐Anorexia ☐☐BingeEatingDisorder ☐☐NightEatingSyndrome ☐☐EatingDisorder(non-specific) ☐☐Other

CANCER☐☐

GENITALANDURINARYSYSTEMS

☐☐KidneyStones ☐☐FrequentUrinaryTractInfections ☐☐FrequentYeastInfections ☐☐Other

MUSCULOSKELETAL/PAIN☐☐Arthritis ☐☐Fibromyalgia ☐☐ChronicPain ☐☐Other

INFLAMMATORY/AUTOIMMUNE☐☐ChronicFatigueSyndrome ☐☐AutoimmuneDisease ☐☐RheumatoidArthritis ☐☐LupusSLE ☐☐ImmuneDeficiencyDisease ☐☐SevereInfectiousDisease ☐☐PoorImmuneFunction (frequentinfections)☐☐FoodAllergies ☐☐EnvironmentalAllergies ☐☐MultipleChemicalSensitivities ☐☐LatexAllergy ☐☐Other

RESPIRATORYDISEASES☐☐FrequentEarInfections ☐☐FrequentUpperRespiratoryInfections ☐☐Bronchitis ☐☐ChronicSinusitis ☐☐Asthma ☐☐SleepApnea

☐☐Other

SKINDISEASES☐☐Eczema ☐☐Psoriasis ☐☐Acne ☐☐Other

þ=PastConditionþ=OngoingCondition

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NEUROLOGIC/MOOD

☐☐Depression ☐☐SensoryIntegrativeDisorder ☐☐Anxiety ☐☐Autism ☐☐BipolarDisorder ☐☐MildCognitiveImpairment ☐☐Schizophrenia ☐☐MultipleSclerosis ☐☐Headaches ☐☐ALS ☐☐Migraines ☐☐Seizures ☐☐ADD/ADHD ☐☐OtherNeurologicalProblems PREVIOUSEVALUATIONS ☐MRI Checkboxifyesandprovidedate ☐CTScan ☐FullPhysicalExam ☐UpperEndoscopy ☐PsychologicalEvaluations ☐UpperGISeries ☐WechslerPreschool&Primary ☐Ultrasound ScaleofIntelligence ☐SpeechandLanguageEvaluation INJURIES☐GeneticEvaluation Checkboxifyesandprovidedate ☐NeurologicalEvaluations ☐BackInjury ☐GastroenterologyEvaluations ☐NeckInjury ☐Celiac/GlutenTesting ☐HeadInjury ☐AllergyEvaluation ☐BrokenBones ☐NutritionalEvaluation ☐Other ☐VisionEvaluation ☐Osteopathic SURGERIES☐Acupuncture ☐Appendectomy ☐PhysicalTherapy ☐Circumcision ☐OccupationalTherapy ☐Hernia ☐SensoryIntegrationTherapy ☐Tonsils ☐LanguageClasses ☐Adenoids ☐SignLanguage ☐DentalSurgery ☐Homeopathic ☐TubesinEars ☐Naturopathic ☐Other ☐Craniosacral ☐Chiropractic BLOODTYPE:☐A ☐B ☐AB ☐O Rh:☐+☐-☐unknownHOSPITALIZATIONS ☐NoneDate Reason

HOSPITALIZATIONS

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Isyourchilduptodatewithimmunizations?☐Yes☐NoDoyoufeelimmunizationshavehadanimpactonyourchild’shealth?☐Yes☐NoIfrelevant,attachacopyofyourchild’simmunizationrecordorseeaddendum.PHSYCHOSOCIALHasyourchildexperiencedanymajorlifechangesthatmayhaveimpactedhis/herhealth?☐Yes☐NoHasyourchildeverexperiencedanymajorlosses?☐Yes☐NoSTRESS/COPINGHaveyoueversoughtcounselingforyourchild?☐Yes☐NoIsyourchildorfamilycurrentlyintherapy?☐Yes☐NoDescribe: Doesyourchildhaveafavoritetoyorobject?☐Yes☐NoCheckallthatapply:☐Yoga☐Meditation☐Imagery☐Breathing☐Prayer☐Other: Hasyourchildeverbeenabused,avictimofacrime,orexperiencedasignificanttrauma?☐Yes☐NoSLEEP/RESTAveragenumberofhoursyourchildsleepspernight:☐>12☐10-12☐8-10☐<8Doesyourchildhavetroublefallingasleep?☐Yes☐NoDoesyourchildfeelresteduponwaking?☐Yes☐NoDoesyouchildsnore?☐Yes☐NoROLES/RELATIONSHIPListFamilyMembers:

FamilyMemberandRelationship Age Gender Whoarethemainpeoplewhocareforyourchild?

Whatistheiremployment/Occupation?

Whatareyourchild’sresourcesforemotionalsupport?Checkallthatapply:☐Spouse☐Family☐Friends☐Religious/Spiritual☐Pets☐Other:

MENSTRUALHISTORY

Ageatfirstperiod: MensesFrequency Length: Pain?☐Yes☐No Clotting?☐Yes☐NoHasyourchild’speriodeverskipped? Forhowlong? LastMenstrualPeriod: Useofhormonalcontraceptionsuchas:☐BirthControlPills☐Patch☐NuvaRingHowlong? Isyourchildsexuallyactive?☐Yes☐NoDoesyourchildusecontraception?☐Yes☐NoType:☐Condom☐Diaphragm☐IUDFEMALEDISORDERS/HORMONALIMBALANCES

☐FibrocysticBreasts ☐Endometriosis ☐Fibroids ☐Infertility☐PainfulPeriods ☐HeavyPeriods ☐PMS

GYNECOLOGICHISTORY(FEMALESONLY)

GIHISTORY

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ForeignTravel?☐Yes☐NoWhere? WildernessCamping?☐Yes☐NoWhere? Haveyoueverhadsevere:☐Gastroenteritis☐Diarrhea

DENTALSURGERY☐SilverMercuryFillings:HowMany? ☐GoldFillings ☐RootCanals ☐Implants☐ToothPain☐BleedingGums☐Gingivitis ☐ProblemswithChewingDoesyourchildflossregularly?☐Yes☐No

MOTHER’SPASTPREGNANCIES☐Unknown,mychildisadoptedNumberof:Pregnancies: LiveBirths: Miscarriages: MOTHER’SPREGNANCYCheckboxifyesandprovideadescriptionifapplicable.

☐Difficultygettingpregnant(morethan6months) ☐GroupBstrepinfection ☐Infertilitydrugsused.Specify: ☐C-sectiondueto: ☐Invitrofertilization ☐Usedinductionforlabor ☐Drankalcohol ☐Hadanesthesia–type ☐Drankcoffee ☐Usedoxygenduringlabor ☐Smokedtobacco ☐Hadanx-ray ☐TookProgesterone ☐HadRhogam,ifsohowmanyshots? ☐Tookprenatalvitamins Howmanywhenpregnant? ☐Tookantibiotics☐DuringLabor? ☐GestationalDiabetes ☐Tookotherdrugs.Specify ☐Highbloodpressure(pre-eclampsia) ☐Excessivevomiting,nausea(morethan3weeks) ☐Highbloodpressure/toxemia ☐Hadaviralinfection ☐Hadchemicalexposure ☐Hadayeastinfection ☐Fatherhadchemicalexposure ☐Hadamalgamfillingsputinteeth ☐Movedtoanewlybuilthouse ☐Hadamalgamfillingsremovedfromteeth ☐Housepaintedindoors ☐Numberoffillingsinteethwhenpregnant? ☐Housepaintedoutdoors ☐Hadbleeding(whichmonths?) ☐Houseexterminatedforinsects ☐Hadbirthproblems ☐HadTdap(WhoopingCough)Vaccination PREGNANCYTotalweightgainduringpregnancy: lb Totalweightlossduringpregnancy: lbPleasedescribedietduringpregnancy: Pleasedescribelabor:

DENTALHISTORY

PATIENTBIRTHHISTORY

PATIENTBIRTHHISTORY

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PERINATALPregnancyduration:Checkfollowingtheweekofgestation.☐24☐25☐26☐27☐28☐29☐30☐31☐32☐33☐34☐35☐36☐37☐38☐39☐40(fullterm)☐41☐42☐43☐44WeeksVeryactivebeforebirth?☐Yes☐NoHospital/BirthingCenter?☐Yes☐NoNeedednewbornspecialcare?☐Yes☐NoAppearedhealthy?☐Yes☐NoEasilyconsoledduringfirstmonth?☐Yes☐NoAntibioticsinthefirstmonth?☐Yes☐NoExperiencednocomplicationsfirstmonthoflife?☐Yes☐NoBIRTHWEIGHTANDAPGARWeightatbirth: lbs Apgarscoreatoneminute: Apgarscoreat5minutes: EARLYCHILDHOODILLNESSESNumberofearachesinthefirsttwoyears: Numberofotherinfectionsinthefirsttwoyears: Numberoftimesyouhadantibioticsinthefirsttwoyearsoflife: Firstantibioticat months.Firstillnessat months.DESCRIPTIONOFDEVELOPMENTALPROBLEMSIfyourchildhasdevelopmentalproblems,atwhatagedidtheyoccur?☐0-1months☐2-6months☐7-15months☐16-24months☐After24monthsIsthisimpressionsharedamongparentsandotherscaringforthechild?☐Yes☐NoIstheimpression,astothetimingofonset,weak?☐Yes☐NoIstheimpressionstrong?☐Yes☐NoDEVELOPMENTALHISTORYPleaseindicatetheapproximateageinmonthsforthefollowingmilestones:(example:walking14months)Sittingup months☐Never Dryatnight months☐NeverCrawling months☐Never Firstwords months☐NeverPulledtostand months☐Never Spokeclearly months☐NeverPottytrained months☐Never Lostlanguage months☐NeverWalkedalone months☐Never Losteyecontact months☐Never

MEDICATIONS

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CURRENTMEDICATIONS

Medication Dose FrequencyStartDateMo/Yr ReasonForUse

PREVIOUSMEDICATIONSLast10years

Medication Dose FrequencyStartDateMo/Yr ReasonForUse

Hasyourchild’smedicationsorsupplementsevercausedhim/herunusualsideeffectsorproblems?☐Yes☐No Describe: HasyourchildhadprolongedorregularuseofNSAIDS(Advil,Aleve,etc.),Motrin,orAspirin?☐Yes☐NoHasyourchildhadprolongedorregularuseofTylenol?☐Yes☐NoHasyourchildhadprolongedorregularuseofAcidBlockingDrugs?(Tagamet,Zantac,Prilosec,etc.)☐Yes☐NoFrequentantibiotics>3times/year?☐Yes☐NoLongtermantibiotics?☐Yes☐NoUseofsteroids(prednisone,nasalallergyinhalers)inthepast?☐Yes☐NoUseoforalcontraceptives?☐Yes☐No FAMILYHISTORY

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☐Unknown,mychildisadopted.

Checkfamilymembersthatapply Mother

Father

Brother(s)

Sister(s)

Children

Maternal

Grandm

other

Maternal

Grandfather

Paternal

Grandm

other

Paternal

Grandfather

Aunts

Uncles

Other

Age(ifsillalive)

Ageatdeath(ifdeceased)

Cancers

ColonCaner

BreastorOvarianCancer

HeartDisease

Hypertension

Obesity

Diabetes

Stroke

InflammatoryArthritis(Rheumatoid,Psoriatic,AnkylosingSpondylitis)

InflammatoryBowelDisease

MultipleSclerosis

AutoImmuneDiseases(suchasLupus)

IrritableBowelSyndrome

CeliacDisease

Asthma

Eczema/Psoriasis

FoodAllergies,SensitivitiesorIntolerances

EnvironmentalSensitivities

Dementia

Parkinson’s

ALSorotherMotorNeuronDiseases

GeneticDisorders

SubstanceAbuse(suchasalcoholism)

PsychiatricDisorders

Depression

Schizophrenia

ADHD

Autism

BipolarDisease

Other

NUTRITIONHISTORY

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Hasyourchildeverhadanutritionconsultation?☐Yes☐NoHaveyoumadeanychangesinyourchild’sdietbecauseofhealthissues?☐Yes☐NoDescribe: Doesyourchildfollowaspecialdietornutritionalprogram?☐Yes☐NoCheckallthatapply☐YeastFree☐Feingold☐Weightmanagement☐Diabetic☐DairyFree☐WheatFree☐Ketogenic☐SpecificCarbohydrate☐GlutenFree☐GlutenRestricted☐Vegetarian☐Vegan☐LowOxalate☐FoodAllergy(Ex.Peanuts,Eggs,etc): Doesyourchildavoidanyparticularfoods?☐Yes☐NoIfyes,whatarethetypesandreasons? Ifyourchildcouldonlyeatafewfoodsdaily,whatwouldtheybe? Whodoesthegroceryshoppinginyourhousehold? Whodoesthecookinginyourhousehold? Howmanymealsdoesyourchildeatoutperweek?☐0-1☐1-3☐3-5☐>5mealsperweekCheckallthefactorsthatapplytoyourchild’scurrentlifestyleandeatinghabits:☐FastEater ☐Mostfamilymealstogether☐Erraticeatingpattern ☐Usefoodasabribeorreward☐Eattoomuch ☐Erraticmealtimes☐Dislikehealthyfood ☐Highjuiceintake☐Timeconstraints ☐Lowfruit/vegetableintake☐Eatmorethan50%mealsawayfromhome ☐Highsugar/sweetintake☐Poorsnackchoices ☐Drinkssodaordietsoda☐Sensoryissueswithfood ☐Cow’smilk123+ ☐Pickyeater ☐Eattoolittleunderstress☐Preferscoldfood ☐Caffeineintake☐Prefershotfood ☐TVorvideoswithmeals☐Everymealisastruggle ☐Challengeswithfoodservedoutsidethehome(ex.childcare)BREASTFEDHISTORYBreastfed?☐Yes☐NoHowlong? Problemslatchingon?☐Yes☐NoSuckingquality:☐VeryGood☐Good☐PoorExclusivelybreastfedfor monthsBOTTLEFEDHISTORYBottlefed?☐Yes☐NoTypeofformula:☐Soy☐Cow’sMilk☐LowAllergyIntroductionofcow’smilkat months.Introductionofsolidfoodsat months.Introductionofwheatorothergrainat months.Choke/Gas/Vomitonmilk?☐Yes☐NoRefusedtochewsolids?☐Yes☐NoListmother’sknowfoodallergiesofsensitivities: Pleaselistanyothereatingconcernsyouhaveregardingyourchild:

Height(feet/inches) CurrentWeight Unusualweightfluctuations? ☐Yes☐No+/- lbs

ACTIVITY

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Listdailytypeandamountofactivity.Type AmountDaily Howmuchtimedoesyourchildspendwatchingtelevision? Howmuchtimedoesyourchildspendonthecomputer,tablet,smartphone,orplayingvideogames?

PleasecheckappropriateboxEXPOSURESPast/Current

☐☐Moldinbathroom ☐☐Moldincellar,crawlspace,orbasement☐☐Dampcellar ☐☐Moldy,mustyschool/daycare☐☐Pestextermination–Inside ☐☐Tobaccosmoke☐☐Pestextermination–Outside ☐☐Wellwater☐☐Forcedhotairheat ☐☐Carpetinbedroom☐☐Hadwaterinbasement ☐☐Carpetinmostpartsofthehouse☐☐Moldvisibleonexteriorofhouse ☐☐Featherordownbedding☐☐Heavilywoodedordampsurroundings

Whenwereyourparentsmarried: Ifseparated,when?: Ifdivorced,when?: Ifremarried,when?: Custodyarrangements: MOTHER–PERSONAL FATHER–PERSONALAgeatyourbirth Ageatyourbirth Education Education Ethnicity Ethnicity BloodType BloodType SYMPTOMREVIEW

EVIRONMENTALHISTORY

ABOUTYOURPARENTS

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Pleasecheckallcurrentsymptomsoccurringorpresentinthepast6months.STRENGTHS☐Especiallyattractive☐Acceptsnewclothes☐Cuddle☐Physicallycoordinated☐Happy☐Pleasant/easytocarefor☐Sensitive/affectionate☐Wantstobeliked☐Responsible☐Drawsaccuratepictures☐Sensitivetopeoplesfeelings☐OKifparentsleave☐Answersparents☐Followsinstructions☐Pronounceswordswell☐Unusualmemory☐Perfectmusicalpitch☐Goodwithmath☐Goodwithcomputer☐Goodwithfinework☐Goodthrowingandcatching☐Goodclimbing☐Strongdesiretodothings☐Swimming☐Bold,freeoffear☐Likestobeheld☐LikestobeswaddledSLEEP☐Sleepsinownbed☐Sleepswithparent(s)☐Awakensscreaming/crying☐Awakesatnight☐Difficultyfallingasleep☐Earlywaking☐Insomnia☐Sleepslessthannormal☐Daytimesleepiness☐Jerksduringsleep☐Nightmares☐SleepsmorethannormalPHYSICAL☐Lookssick☐Glazedlook☐Overweight☐Underweight

☐Pupilsunusuallylarge☐Unusuallongeyelashes☐Redlips☐Redfingers☐Redtoes☐Webbedtoes☐Redears☐Doublejointed☐Higharchedpalate☐Lymphnodesenlargedinneck☐Headwarm☐Headsweats☐Nightsweats☐Abnormalfatigue☐Failuretothrive☐Coldallover☐Coldhandsandfeet☐Coldintolerance☐Sweatyhands/feet☐Sweaty/hothead☐Perspiration–oddodorSKIN☐Paleness,severe☐Fingernailfungus☐Toenailfungus☐Dandruff☐Chickenskin☐Oilyskin☐Patchydullness☐Seborrheaonface☐Thickcalluses☐Athletesfoot☐Stinkyfeet☐DiaperRash☐Strongbodyodor☐Acne☐Eczema☐Flushing☐Redface☐Sensitivetoinsectbites☐StretchMarks☐Blotchyskin☐Frequentbugbites☐Cradlecap☐Dryhair☐Dryscalp☐Unmanageablehair

☐Bitesnails☐Brittlenails☐Frayednails☐Pittednails☐Softnails☐Darkbirthmarks☐Bruiseseasily☐Inabilitytotan☐Lightbirthmark☐Raggedcuticles☐Thickeningfingernails☐Thickeningtoenails☐Vitiligo☐Whitespotsorlinesinnails☐Dryskin☐Feetcracking☐Feetpeeling☐Handscracking☐Handspeeling☐Lowerlegsdry☐Lacklusterskin☐Itchyskiningeneral☐Itchyscalp☐Itchyearcanals☐Itchyeyes☐Itchynose☐Itchyroofofmouth☐Itchyarms☐Itchyhands☐Itchylegs☐Itchyfeet☐Itchyanus☐Itchypenis☐ItchyvaginaDIGESTIVE☐Badbreath☐IncreasedSalivation☐Drooling☐Crackedlipcorners☐Coldsoresonlips/face☐Geographictongue(map-like)☐Soretongue☐Tonguecoated☐Cankersoresinmouth☐Bleedinggums☐Teethgrinding☐Toothcavities

☐Toothwithamalgamfillings☐Mouththrush(yeast)

☐Sorethroat☐Fecalbelching

☐Burping☐Nausea

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☐Reflux☐Spittingup☐Vomiting☐Abdominalbloating☐Lowerabdominalbloating☐Colic☐Abdomendistended☐Abdominalpain☐Intestinalparasites☐Pinworms☐Crampypainwithpooping☐Constipation☐Diarrhea☐Gas–regular☐Gas–Stinky☐Analfissures☐Redringaroundanus☐Stoolsbulky☐Stoolslightcolor☐Stoolsverystinky☐Stoolswithblood☐Stoolswithmucous☐Stoolswithundigestedfood☐Stoolodoryeasty☐Stoolsslimy☐StoolswateryEATING☐Poorappetite☐Thirst☐Extremewaterdrinking☐Bingeing☐Breadcraving☐Cravingforcarbohydrates☐Cravingforjuice☐Cravingforsalt☐Dietsodacraving☐Pica(eatingnon-edibles)☐Abnormalfoodcravings☐Carbohydrateintolerance☐Starchintolerance☐Sugarintolerance☐Salicylateintolerance☐Oxalateintolerance☐Phenolicintolerance☐MSGintolerance☐Foodcoloringintolerance☐Glutenintolerance☐Caseinintolerance☐Specificfood(s)intolerance☐Lactoseintolerance☐Behaviorworsewithfood☐Behaviorbetterwhenfasting

BEHAVIOR☐Behaviorpurposeless☐Unusualplay☐Usesadultshandforactivity☐Aloof,indifferent,remote☐Doesn’tdoforself☐Extremelycurious☐Hidesskill/knowledge☐Lacksinitiative☐Lostinthought,unreachable☐Nopurposetoplay☐Poorfocus,attention☐Sitslongtimestaring☐Uninterestedinlivepet☐Watchestelevisionlongtime☐Won’tattempt/can’tdo☐Poorsharing☐Rejectshelp☐Curious/getsintothings☐Erratic☐Unabletopredictactions☐Destructive☐Hyperactive☐Constantmovement☐Meltdowns☐Tantrums☐Selfmutilation☐Runsaway☐Jumpswhenpleased☐Whirlsselflikeatop☐Climbstohighplaces☐Insistsonwhatiswanted☐Triestocontrolothers☐Headbanging☐Falls,getshurtrunning/climbing☐Doesoppositeofasked☐Teasesothers☐Silly☐Shrieks☐Holdshandsinstrangepose☐Spendstimew/pointlesstask☐Staresatownhands☐Toewalking☐Archedbackwithbrightlights☐Imitatesothers☐Fingerflicking☐Flapshands☐Licking☐Likesspinningobjects☐Likestoflickfingerineye☐Liketospinthings☐Rhythmicrocking☐Slappingbooks☐Toothtapping

☐Visualstims☐Wigglefingerfrontofface☐Wigglefingersideofface☐Bitesorchewsfingers☐Biteswristorbackofhands☐ChewsonthingsMOOD☐Apathy☐Blanklook☐Depression☐Detached☐Disinterested☐Eyecontactpoor☐Isolates☐Negative☐Frightwithoutcause☐Alwaysfrightened☐Anguish☐Discontented☐Doesnotwanttobetouched☐Inconsolablecrying☐Irritable☐Lookslikeinpain☐Moaning,groaning☐Phobias☐Restless☐Severemoodswings☐Unhappy☐Agitated☐AnxiousSENSORY☐Botheredbycertainsounds☐Coversearswithsounds☐Earpain☐Earringing☐Hearingacute☐Hearingloss☐Likescertainsounds☐Sensitivetoloudnoise☐Soundsseempainful☐Tinnitus☐Acutesenseofsmell☐Examinesbysmell☐Intenselyawareofodors☐Blinking☐Botheredbybrightlights☐Distortedvision☐Conjunctivitis☐Eyecrusting☐Eyeproblem☐Lidmarginredness☐Examinesbysight

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☐Failstoblinkatbrightlight☐Likesfans☐Likesflickeringlights☐Looksoutofcornerofeye☐Poorvision☐Putseyetobrightlightorsun☐Strabismus(crossedeyes)☐Fearfulofharmlessobject☐Fearfulofunusualevents☐Unawareofdanger☐Unawareofpeople’sfeelings☐Unawareofselfasperson☐Upsetifthingschange☐Upsetifthingsaren’tright☐Adoptscomplicatedrituals☐Car,truck,trainobsession☐Collectsparticularthings☐Drawsonlycertainthings☐Fixatedononetopic☐Linesobjectsprecisely☐Repeatsoldphrases☐Repetitiveplay/objects☐Fingertipsqueezing☐Hateswearingshoes☐Insensitivetopain☐Likesheadburrowed☐Likedheadpressedhard☐Likesheadrubbed☐Likesheadunderblanket☐Likestobeheldupsidedown☐Likestobeswungintheair☐Veryinsensitivetopain☐VerysensitivetopainNEUROMUSCULAR☐Clumsiness☐Coordination☐Poorfinemotorskills☐Poorgrossmotorskills☐Holdsbizarreposture☐Hyperactivity☐Physicallyawkward☐Rocking☐Stiffensbodywhenheld☐Calfcramps☐Footcramps☐Musclepain

☐Muscletonetense☐Muscletwitches☐Fistclenching☐Jawclenching☐Poormuscletone/limp☐Tics☐Muscletonelowtrunk☐Muscleweakness,atrophy☐Muscletonelowallover☐Tremors☐Cognitivedelays☐Memorypoor☐Poorattention☐Slowandsluggish☐ExpressivelanguagedelaySPEECH☐Neverspoke☐Occasionalwordswhenexcited☐Expressivelanguagepoor☐Doesn’tsimplequestions☐Pointstoobjects/can’tname☐Speechapraxia☐Doesnotaskquestions☐Babbling☐Asksusing“you”not“I”☐Answersbyrepeatingquestions☐Receptivelanguagepoor☐Says“I”☐Says“no”☐Says“yes”☐Lostlanguage@12-24months☐Lostlanguageafter24months☐Scripting☐Stuttering☐Talkstoself☐Poorauditoryprocessing☐Unusualsoundofcry☐Usesonewordforanother☐Rigidbehaviors☐Poorconfidence☐Timid☐Correctsimperfections☐TidyRESPIRATORY☐Pneumonia

☐Badodorinnose☐Breathholding☐Bronchitis☐Congestionchg.Season☐Congestioninthefall☐Congestioninthespring☐Congestioninthesummer☐Congestioninthewinter☐Cough☐Postnasaldrip☐Runnynose☐Sighing☐Sinusfullness☐Wheezing☐YawningREPRODUCTIVE☐EarlypubichairGirls:☐Earlyfirstperiod☐EarlyBreastDevelopment☐VaginalodorBoys:☐Largetesticles☐LargebreastsURINARY☐Frequenturination☐Bedwettingafterage4☐Oddurinaryodor☐Urinaryhesitancy☐Urinarytractinfections☐Urinaryurgency☐DryatnightOTHER☐Seizures–focal☐Seizures–generalized☐Seizures–grandmal☐Unusualfastheartbeat☐Heatmurmur☐Headaches☐Jointpains☐Legpains☐Musclepains

READINESSASSESSMENT

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Rateonascaleof:5(verywilling)to1(notwilling).Inordertoimproveyourchild’shealth,howwillingisthepatientin: Significantlymodifydiet:☐5☐4☐3☐2☐1 Takeseveralnutritionalsupplementseachday:☐5☐4☐3☐2☐1 Keeparecordofeverythingyoueateachday:☐5☐4☐3☐2☐1 Modifylifestyle(e.g.,school/homedemands,sleephabits):☐5☐4☐3☐2☐1 Practicearelaxationtechnique:☐5☐4☐3☐2☐1 Engageinregularexercise:☐5☐4☐3☐2☐1 Haveperiodiclabteststoassessprogress:☐5☐4☐3☐2☐1Comments: Rateonasaleof:5(veryconfident)to1(notconfidentatall)Howconfidentareyouofyourabilitytoorganizeandfollowthroughontheabovehealthrelatedactivitiestohelpyourchild?:☐5☐4☐3☐2☐1Ifyouarenotconfidentofyourability,whataspectsofyourselforlifeleadyoutoquestionyoucapacitytofullyengageintheaboveactivities? Rateonasaleof:5(verysupportive)to1(veryunsupportive)Atthepresenttime,howsupportivedoyouthinkthepeopleinyourhouseholdwillbetoyourimplementingtheabovechanges?☐5☐4☐3☐2☐1Comments: Rateonascaleof:5(veryfrequentcontact)to1(veryinfrequentcontact)Howmuchon-goingsupportandcontact(e.g.telephoneconsults,emailcorrespondence)fromourprofessionalstaffwouldbehelpfultoyouasyouimplementapersonalhealthprogramforyourchild?☐5☐4☐3☐2☐1Comments: