Has your child ever had: Ear infections Yes No ☐ ☐ Nose problems (sinus infections, nose bleeds) Yes No ☐ ☐ Eye problems (blurry vision, need to wear glasses) Yes No ☐ ☐ Hearing problems Yes No ☐ ☐ Mouth or throat problems (Strep throat, swallowing problems) Yes No ☐ ☐ Diarrhea (having frequent and runny bowel movements/poop) Yes No ☐ ☐ Constipation (problems having a bowel movement /poop) Yes No ☐ ☐ Throwing up (vomiting) Yes No ☐ ☐ Problems (bed wetting, pain when peeing) peeing Yes No ☐ ☐ Back problems (crooked back, back pain) Yes No ☐ ☐ Growing pains (bone or body pains due to growing) Yes No ☐ ☐ Muscle and bone problems (weak muscles, pain in joints) Yes No ☐ ☐ Skin problems (acne, flaking skin, rashes, hives) Yes No ☐ ☐ Seizures (shaking fits) Yes No ☐ ☐ ADD/ADHD (problems paying attention, sitting still) Yes No ☐ ☐ Sleeping problems (falling or staying asleep) Yes No ☐ ☐ Breathing problems (cough, asthma) Yes No ☐ ☐ Warts Yes No ☐ ☐ Jaundice (yellow skin) Yes No ☐ ☐ SHOTS 9. Has your child received immunizations (shots) in the past? No (If no, go to question #10.) ☐ Yes ☐ If yes, have you given this office a copy of the immunization (shots) records? (If Yes, go to question #10.) ☐Yes ☐No If not, please give us the name of the or clinics where your child has received doctors’ offices these shots so we can get the records. Doctor’s office/clinic name: phone number: Doctor’s office/clinic ABOUT MOM WHEN PREGNANT
Has your child ever had: Ear infections ☐ Yes ☐ No Nose problems (sinus infections, nose bleeds) ☐ Yes ☐ No Eye problems (blurry vision, need to wear glasses) ☐ Yes ☐ No Hearing problems ☐ Yes ☐ No Mouth or throat problems (Strep throat, swallowing problems) ☐ Yes ☐ No Diarrhea (having frequent and runny bowel movements/poop) ☐ Yes ☐ No Constipation (problems having a bowel movement /poop) ☐ Yes ☐ No Throwing up (vomiting) ☐ Yes ☐ No Problems peeing (bed wetting, pain when peeing) ☐ Yes ☐ No Back problems (crooked back, back pain) ☐ Yes ☐ No Growing pains (bone or body pains due to growing) ☐ Yes ☐ No Muscle and bone problems (weak muscles, pain in joints) ☐ Yes ☐ No Skin problems (acne, flaking skin, rashes, hives) ☐ Yes ☐ No Seizures (shaking fits) ☐ Yes ☐ No ADD/ADHD (problems paying attention, sitting still) ☐ Yes ☐ No Sleeping problems (falling or staying asleep) ☐ Yes ☐ No Breathing problems (cough, asthma) ☐ Yes ☐ No Warts ☐ Yes ☐ No Jaundice (yellow skin) ☐ Yes ☐ No SHOTS 9. Has your child received immunizations (shots) in the past? ☐ No (If no, go to question #10.) ☐ Yes If yes, have you given this office a copy of the immunization (shots) records? ☐Yes (If Yes, go to question #10.) ☐No If not, please give us the name of the doctors’ offices or clinics where your child has received these shots so we can get the records. Doctor’s office/clinic name: Doctor’s office/clinic phone number: ABOUT MOM WHEN PREGNANT
healthlittoolkit2-tool11b.docx