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Reason for visit today
Is it getting worse? Yes No
Does it effect your
sleep
daily activities
other (please specify in the box below)
What seemed to be the initial cause?
What makes it better?
What makes it worse?
Other Current Treatments
Family Medical History
Has your child been immunized for the following (please check all that apply)
Please indicate if there was any side effect from any of the above immunizations
Child’s Past Medical History (please check any of the following conditions you currently have, or have had in the past)
Surgeries (list)
Major Trauma (car accident, fall, etc.)
Is your child currently on any prescribed medicine? Yes No
Is your child currently taking any non-prescribed medicine (for i.e. herbs, vitamins, supplements etc.)? Yes No
Has your child taken antibiotics before?
Yes No Number of times
Excluding the above listed medicine has your child taken any other medicine in the past?
DIET (please complete the sample menu according to an average day)
Morning
Noon
Evening
Snacks (when and what)
Does your child eat or drink the following (if so how often)?
Was your child breast fed? Yes No
When and how did you introduce solid food?
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