CHILDINTAKEFORM

Thisformiscompletelyconfidential.Pleasesubmitbyemail,fax,mail,orin-person3businessdaysbeforeyourappointment..

PROFILE:

Child'sName: ________________________________________________Gender: M FAge:______

Today'sDate: ______/______/______(dd/mm/yyyy) DateofBirth: ______/______/______(dd/mm/yyyy)

Parent'sName:______________________________________________________________________________________________Address:____________________________________________________________________________________________________________________________________________________________________________________________

Telephone: (Home)______-______-______(Cell)______-______-______(Work)______-______-______

PreferEmailCorrespondence? Y NEmail:____________________________________________________________

Parent'sOccupation:____________________________________Employer:_____________________________________Maritalstatus: Single Married Partnered Divorced Separated Widowed

Child'sSiblings/Ages:________________________________________________________________________________

Howdidyouhearaboutus?__________________________________________________________________________________

Maywegiveyouappointmentremindercalls? Y N(phone)______-______-______

Mayweleaveyouphonemessages? Y N(phone)______-______-______ sameasabove

EMERGENCYCONTACT:

Name: Relationship:

Telephone: (home)______-______-______(cell)______-______-______(work)______-______-______

MEDICALCONTACTS:

NameofMedicalDoctor/FamilyPhysician:

Telephone: ______-______-______

Dateoflastbloodwork: Dateoflastannual/physicalexam:

Listanyotherhealthcareproviders(name,specialty,telephone):

MEDICALHISTORY:Listchild'shealthconcernsinorderofimportance:

1.___________________________________________

2.___________________________________________

3.___________________________________________

4.___________________________________________

5.___________________________________________

Hasanyhealthconcernrecentlychangedorbecomeworse? Y N____________________________________________________________________________________________________________Howwouldyoudescribeyourchild'sgeneralstateofhealth? Excellent Good Fair PoorWhathasyourdoctor(currently&previously)diagnosedyourchildwith?________________________________________________________________________________________________________________________________________________________________________________________________________________________

Pleaselistallcurrentmedications(prescriptionorover-the-counter)andsupplements(herbs,vitamins)

NameofDrug/Supplement UsedFor DateStarted Dose/Frequency

Listpastprescriptionmedications:_____________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Listanyknownallergies(includedrugs,food,environmental,chemicalandetc.)andthereaction(s)fromthem.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Hasyourchildundergoneanytypeofallergyand/orfoodsensitivitytesting? Y N

Ifyes,whatkindoftestingandtheresults:_____________________________________________________________________

____________________________________________________________________________________________________________

Child'sPresentWeight:____________

Child'sWeight(1yearago):____________

Child'sPresentHeight: ____________

PRE-NATALHEALTH:

Whatwastheparent'shealthatconception?(spermjoiningegg)

Mother: Poor Fair Good Excellent Other:_____________________________________________

Father: Poor Fair Good Excellent Other:____________________________________________

Mother'sageatchild'sbirth:_________ Didthemotherreceivepre-natalmedicalcare? Y N

Mother'sfirstpregnancy: Y NChild'sbirthorder: First Last Middle Only

Mother'shealthduringpregnancy: Poor Fair Good Excellent Other:__________________________

Didthemotherexperienceanyofthefollowingduringpregnancy:

Bleeding Diabetes Nausea Vomiting Highbloodpressure Thyroidissues

PhysicalorEmotionaltrauma Other:________________________________________________________________

Didthemotheruseanyofthefollowingduringpregnancy?

Tobacco Alcohol Recreationaldrugs Antibiotics Other:_____________________________________

BIRTHHISTORY:

Termlength: Full Premature______weeks Late______weeks

Birthweight:______lbs.______oz. BirthLength:__________

Methodofdelivery: Vaginal C-section Induced Forceps Anesthesiaused

Listanycomplicationsduringlabor:____________________________________________________________________________

____________________________________________________________________________________________________________

Didthechildexperienceanyofthefollowingat/orshortlyafterbirth:

Jaundice Rashes Seizures Other:________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Listanytraumas(mental,emotional,physical),injury,illness,surgeryorhospitalizations:

Incident Date Long-termeffects

Notewhenandwhyyourchildhashadanyofthefollowing:

X-Rays:

MRI:

Ultrasounds:

CATScans:

TuberculosisTest:

LastDentalWork:

HIVTest:

LastEyeExam:

CHILDHOODILLNESSES:(checkallthatapply)

Chickenpox Measles Mumps Rubella Rheumaticfever

Scarletfever Tuberculosis Pertussis Asthma SeasonalAllergies

EarInfections TotalEarInfections(in1year): _________________________________________________________

Colds TotalColds(in1year): _________________________________________________________

StrepThroatTotalStrepThroats(in1year): _________________________________________________________

Other:__________________________________________________________________________________________________

Howmanytimeshasyourchildbeentreatedwithantibiotics?____________________________________________________

Forwhatcondition(s):________________________________________________________________________________________

____________________________________________________________________________________________________________

Hasyourchildeverusedprobioticsafterantibioticuse? Y N_______________________________________________

VACCINATIONS:(checkallthatapply)

DPT(diptheria,pertussis,tetanus) HIB(haemophilusinfluenzeB) Smallpox Varicella(chickenpox)

MMR(measles,mumps,rubella) Polio Gardasil(HPV) HepatitisA

HepatitisB SeasonalFlushot TetanusBooster RotaVirus

Meningococcal Pneumococcal Unknown

Adversereactionstoanyvaccines(whatyouwitnessed,notwhatyouweretold"couldn'tpossiblyhappen"): Y N

Ifyes,pleaseexplain:________________________________________________________________________________________

____________________________________________________________________________________________________________

FAMILYHISTORY:Pleaseindicateifyourchild'simmediatefamilyhashadanyofthefollowingconditions:

Condition FamilyMember(s) Condition FamilyMember(s)

Alcoholism/Drugabuse Epilepsy

Allergies/Hayfever Heartdisease

Arthritis Highbloodpressure

Asthma/Emphysema Kidneydisease

Auto-immunedisease Liverdisease

Bleedingdisorder Mentalillness

Cancer Overweight/Obesity

Diabetes Stroke

Digestivedisorder Thyroidproblems

Eatingdisorder Other:

Don'tknowchild'sfamilymedicalhistory:(pleaseexplainwhy)__________________________________________

________________________________________________________________________________________________

DEVELOPMENT/DIET/DIGESTION/LIFESTYLE/ENVIRONMENTAL:Atwhatagedidyourchildfirst:Situp:_______Crawl:_______Walk:_______Talk:_______

Howmanyhoursdoesyourchildsleepnightly?_________________________________________________________________

Isyourchild: Athome Indaycare InschoolandGrade:__________ Other:____________________

Howwouldyoudescribeyourchild'stemperament?_____________________________________________________________

Howwouldyoudescribeyourchild'senergy?___________________________________________________________________

Howwouldyoudescribetheemotionalclimateofthechild'shome?______________________________________________

Howwouldyoudescribeyourchild'sbehaviorandperformanceatschool?_________________________________________

Whatareyourchild'sfavoriteactivities?_______________________________________________________________________

__________________________________________________________________________________________________

Howmuchtelevisiondoesyourchildwatch?(hoursaday/week)__________________________________________________

Doesyourchildexerciseregularly? Y NType:____________________________________________________________

Howis/wasyourchildfed? BreastfedandDuration:________ FormulaandType:_______ Other:___________

Hasyourchildeverexperiencedcolic? Mild Moderate Severe

Whatfoodswereintroducedbefore6monthsofage(pleaselistapproximatemonthsaswell):_______________________

Whatfoodswereintroducedbetween6and12monthsofage:___________________________________________________

Listanyfoodallergies/sensitivities:___________________________________________________________________________

Childexposedtoenvironmentalpollutants? Y N Unknown

Childexposedtotobaccosmoke? Y N

Childfrequentlyexposedtoanimals? Y N

(Y=current/N=never/P=past)

Nightmares: Y N P Sleepwalk: Y N P

WakeRefreshed: Y N P Mustnapduringtheday: Y N P

Grindteeth: Y N P Snore: Y N P

Pleaserecordyourchild'sdietforthelast3days:

Day1 Day2 Day3

Breakfast

Lunch

Dinner

Doesyourchildhavedietaryrestrictions(religious,vegetarian,vegan)? Y N_______________________________

Howmanyouncesofwaterdoesyourchilddrinkperday?_________Whattypeofwater?______________________

Howoftenareyourchild'sbowelmovements?_______________________________________________________________

Dotheytendtowards? Constipation Diarrhea Both Other:__________________________________

Whatisthecolorofthestool?_______________________Anyundigestedfoodinstool? Y N

Whatistheshapeofthestool? Well-formed Ribbon-like Pellets Other:__________________________

Historyofbed-wetting? Yes No

Historyofsexual,mental/emotionalorphysicalabuse? Y N

Ifso,atwhatageandbywhom?____________________________________________________________________________

__________________________________________________________________________________________________________

Whatisyourchild'sgreatesthealthconcern?___________________________________________________________________

Howdoesitlimitthemthemost?_____________________________________________________________________________

Howcommittedareyou&yourchildtowardsmakingvaluablechanges? Little Moderate Very Don'tKnow

REVIEWOFSYMPTOMS:

(Y=current/Nnever/P=past)(Checkallthatapply)

SKIN

Rash: Y N P Colorchange: Y N P

Hives: Y N P Lump: Y N P

Psoriasis/eczema Y N P Itchy: Y N P

Dry: Y N P Warts/moles: Y N P

Cancer: Y N P Perspiration Y N P

HEAD

Headache: Y N P Migraine: Y N P

Dandruff: Y N P Headinjury: Y N P

Oily/dryhair: Y N P Hairloss: Y N P

NOSE

FrequentColds: Y N P Nosebleeds: Y N P

Congestion: Y N P Postnasaldrip: Y N P

Polyps: Y N P SeasonalAllergies: Y N P

EYES

Dry/Watery: Y N P BlurryVision: Y N P

DoubleVision: Y N P Cataracts: Y N P

Glaucoma: Y N P Styes: Y N P

Strain: Y N P Discharge: Y N P

Itchy: Y N P Darkundereyelid Y N P

MOUTH/THROAT

Cankersores: Y N P Coldsores: Y N P

Sorethroat: Y N P Gumdisease: Y N P

Dentures: Y N P Cavities: Y N P

Lossoftastes: Y N P Hoarsness: Y N P

NECK

Stiffness: Y N P Swollenglands: Y N P

Fullmovement: Y N P Tension: Y N P

RESPIRATORY

Cough: Y N P TB: Y N P

Shortnessofbreathw/exertion:

Y N P Bronchitis Y N P

Shortnessofbreathsitting:

Y N P Pneumonia: Y N P

Shortnessofbreathlyingdown:

Y N P Asthma Y N P

Wheezing: Y N P Painfulbreathing Y N P

CARDIOVASCULAR

HighBloodPressure: Y N P RheumaticFever Y N P

LowBloodPressure: Y N P Murmurs Y N P

Arrhythmias: Y N P Palpitations: Y N P

Edema: Y N P Chestpain: Y N P

URINARYTRACT

Incontinence: Y N P Painw/urination Y N P

FrequentInfections: Y N P KidneyStones Y N P

Urgency Y N P Discharge/blood Y N P

GASTROINTESTINAL

Heartburn: Y N P Parasites Y N P

Indigestion: Y N P Bloodinstool Y N P

Bloating: Y N P Diarrhea Y N P

Nausea: Y N P Constipation Y N P

Vomiting: Y N P Liverdisease: Y N P

Changeinappetite: Y N P Gallbladderdisease Y N P

Pancreatitis: Y N P Ulcer Y N P

MUSKULOSKELETAL

Weakness: Y N P Arthritis: Y N P

Stiffness: Y N P Legcramps: Y N P

Tremors: Y N P GrowingPains: Y N P

NERVOUSSYSTEM

Paralysis: Y N P Sciatica: Y N P

Tingling/numbness: Y N P Carpaltunnel: Y N P

Seizures: Y N P Fainting: Y N P

MENTAL/EMOTIONAL

Depression: Y N P Anger/Irritability Y N P

Suicidal: Y N P Highstrung/tense Y N P

Anxiety Y N P Fear/Panic: Y N P

Eatingdisorder: Y N P SpeechImpediment Y N P

PTSD Y N P LearningImpediment

Y N P

Whatpotentialobstaclesdoyouforeseeinaddressingthelifestylefactors,whichareunderminingyourchild'shealth,andinadheringtothetherapeuticprotocols?

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Whatareyourgoalsandexpectationsafteryourchild'sfirstnewpatientvisitwithDr.Cutler?

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Isthereanyotherinformationthatyoufeelisimportantthathasnotbeencovered?

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Thankyouverymuchfortakingthetimetocompletethisthoroughform.Itwillgreatlyassistintheformulationofanindividualizedprotocolspecifictoyourhealthcareneeds

31350TelegraphRd.Suite102•BinghamFarms,MI48025•248-663-0161•Fax248-594-9493www.cutlerintegrativemedicine.com