Susan M. Seven-Sky, D.C.

263 Columbus Avenue, WestHarrison, NY 10604

914-305-4254

Fax 914-949-0405

Nutritional Integrative Care of Children

Welcome to my practice. Over the next few weeks to months, we will work together to help integrate and mold your child’s health care in a holistic and thorough fashion. We will look at his/her nutritional status, immunology and biochemistry as well as any medications and therapies. We hope to answer any of your questions and concerns.

To begin, please complete the enclosed questionnaire and return to my office at least two weeks prior to your appointment. It is important to be as complete and detailed as possible. Include any symptoms or signs you may see in your child. They may be important clues.

Include all therapies and therapists working with your child. Also please try to include copies of previous studies.

Please allow at least two hours for your first visit. It is important that your child attend. However, because of the length of the visit, we recommend bringing another adult with you if possible to that you can concentrate on the details of your child’s history.

If you are unable to keep your appointment, please call our office at least 24 hours in advance.

We look forward to meeting you and working with you and your child. Please call with any questions.

Sincerely,

Dr. Susan M. Seven-Sky, D.C.

Pediatric History

Name______Date______SSN: ____-_____-___

First MI Last

Address______City______State_____Zip______

Sex _____Female _____Male___Birthdate ______Birth Place______

Home phone ______Work phone______

Do you prefer to receive calls at: _____Home _____Work ___Either

Are you: _____Minor _____ Married _____ Divorced _____ Widowed _____ Single _____Separated

Your employer ______Occupation ______

Business Address ______City ______State _____ Zip ______

Spouse or Parent’s Name ______Work Phone ______

History of Present Illness

Chief Complaint: ______Duration______

When was the patient last entirely well? ______

How and when did the condition begin? ______

Progress of disease: order and date of new symptoms: ______

Specific symptoms and physical signs that may have developed:______

Pertinent negative data obtained by direct questioning:______

Aggravating and alleviating factors:______

Significant medical attention and medications or home therapies given? ______

Over what period of time? ______

In acute infections, statement of type and degree of exposure, and interval since exposure:______For the well child, factors of significance and general condition since the last visit______Examiners opinion of the informants reliability______

Birth History

Antenatal

Basic info on the health of the mother during pregnancy: ______

Prenatal Care: ______Diet: ______

Any infections while pregnant? ______Vomiting? _____ Bleeding? ______Preeclampsia/Eclampsia: ______Rh typing/Serological tests/Pelvimetry/Meds/X-ray procedures/amniocentesis: ______

Natal

Duration of pregnancy: ______Kind and duration of labor: ______Type of delivery: ______Sedation and anesthesia: ______Birth weight: ______State of infant at birth: ______Resuscitation required? ______Onset of respiration: ______First Cry: ______Special procedures? ______

Neonatal

Child’s apgar score: ______Color (cyanotic, pallor, jaundice) and cry: ______

______twitching/ excessive mucous______paralysis/convulsions______

Fever/hemorrhage ______congenital abnormalities/birth injuries ______presence of rashes, difficulty sucking or feeding ______length of hospital stay/ discharge weight______

Development

Milestones

First raised head: ____rolled over: ______sat alone______pulled up______walked with help______walked alone______talked with meaningful words and sentences______urinary continence during night ______during day ______control of defecation ______Comparison of development w/that of siblings and parents ______Any period of failure to grow or unusual growth ______School grade or quality of work ______

Nutrition

Breast or formula fed ______type of feeding ______Duration ______major formula changes ______time of weaning ______difficulties ______

______Any supplements (type, amount, duration of any additional vitamins, fluoride, or iron) ______When were solid foods introduced______How taken? ______types ______Unusual family dietary habits ______

______balancing food groups ______Food likes and dislikes ______idiosyncrasies ______allergies ______general attitude to eating ______

Illnesses

Hospitalizations

Dates and reasons ______

Any infections? ______If so, age(s) at onset: ______type(s) of infection(s) ______number of severity episodes? ___

Any contagious diseases? ______Age at exposure to: Measles______rubella______chickenpox ______mumps _____ pertussis ______diphtheria ______Scarlet fever______Other serious non infectious illnesses ______

Immunizations and Tests

Age at immunizations______Type and number of ______boosters ______reactions if any______

Surgery

Type ______Childs age ______Complications ______

Reasons ______Childs response ______

Any other accidents and/or injuries? ______Nature, severity , and sequellae ______

Any medications? ______

Family History

Basic info. About childs parents:______

Ages and health conditions ______

Basic info. About childs siblings: ______

Ages and health conditions______

Previous Illnesses ______

Childs birth order ______

Mothers childbearing history:

Any: Stillbirths? ______Abortions? ______Miscarriages? ______

Personal History

Social behavior and interests: How does he/she relate to others? (Independent, clingy, shy, aggressive, submissive, extraverted, negativistic)______is there age appropriate separation from parents? ______Does the child have any interests and hobbies that involve interaction to others? ______Easy or difficult to get along with? ______Is the child similar or different to sibling’s ______

Social History

Info about the adults at home and their relationship to the child ______Stability to family structure ______sources of income ______description of home ______Type of neighborhood ______

______Access to play facilities ______Languages spoken at home? ______Child care arrangements ______

______Type and location of school ______students per classroom ______

Childs and parents satisfaction ______Type of health coverage______

Environmental History

Indoor air pollution:

Is Childs health affected by?

House dust ______Mold ______animal dander ______

Fumes from disinfectants ______ventilation problems ______

Does child have access to pesticides and lawn care products? ______

Are there any lead-based paints on household woodwork/furnishings ______

Location of play areas ______local traffic conditions______

Adult supervision ______Sturdiness of equipment ______Any electromagnetic hazards? ______

Personal Habits

Sleeping:

Duration ______Any disturbances (snoring, restlessness, dreaming, nightmares) ______

Recreation:

Exercise ______favorite sports______

Elimination:

Patterns and age appropriateness of urinary and bowel movements: ______

Behavioral concerns:

Problematic behavior? ______Bed wetting ______masturbation ______thumb sucking/nail biting/breath-holding/temper tantrums /tics/nervousness/unduethirst______

School/adolescent problems:

Smoking ______alcohol/substance abuse ______eating/exercise disorders

______abuse of steroids ______sexual activity ______birth control ______knowledge of sexually transmitted disease ______involvement in gangs ______use of guns or other weapons ______

Dental Hygiene:

Date of most recent preventative check ______

Safety:

Use of child seats in autos? ______bicycle helmets ______careful storage of meds/toxic substances______covering outlets______