Patient's Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Mother's Name
First Name
Last Name
Father's Name
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Telephone: Home
*
(###)
###
####
Telephone: Work (M.)
(###)
###
####
Telephone: Work (F.)
(###)
###
####
Telephone: Other (M.)
(###)
###
####
Telephone: Other (F.)
(###)
###
####
Email
*
Referred By
Present M.D. & Phone Number
Major Complaints in Order of Importance (since when have they occurred?)
*
Medications your child is currently taking:
*
Select he following conditions your child has had
*
Other Major Conditions Not Listed:
Are there any of the preceding conditions after which your child has not been totally well again? Which ones?
Any Major Operations/Injuries? (Please note when and if there were complications)
Measles
*
Mumps
*
Rubella/German Measles
*
Chicken Pox
*
Whooping Cough
*
Meningitis
*
Hepatitis B
*
If YES to any of the above, please list any adverse effects from these vaccinations:
Previous pregnancies by natural mother, miscarriages or complications?
Mother’s age at child birth
Mother’s Health during Pregnancy? List any bleeding, nausea, illness, physical or emotional trauma, hypertension, diabetes, medications, alcohol, drug, cigarette consumption, etc
Mother
Father
Brothers
Sisters
Maternal Grandmother
Maternal Grandfather
Maternal Aunts/Uncles
Paternal Grandmother
Paternal Grandfather
Paternal Aunts/Uncles
Which of the following ailments, or any other major ailments, have affected your child’s relatives:
*
Birth History (Select 1)
*
Full Term
Premature
Late
Weight at Birth
*
Length of Labour
*
Complications During Labour
Age your child began: Sitting
Age your child began: Crawling
Age your child began: Walking
Age your child began: First Words
Feeding: Breast Fed & How Long?
Feeding: Formula (Milk/Soy/Other)?
Food Intolerances?
Age Began Solid Foods?
Is there any other information that I need to know?
Have you received the Covid-19 Vaccine?
*
Have you received the Covid-19 Vaccine?
Date of 1st Shot
MM
DD
YYYY
Date of 2nd Shot
MM
DD
YYYY
Date of 1st Booster
MM
DD
YYYY
Date of Signature
*
MM
DD
YYYY
Witness Signature
I give permission for Aimee Marples to use this case in teaching and lectures (confidentiality maintained)