SYMPTOM REVIEW Please check all current symptoms occurring or present in the past 6 months. STRENGTHS circles under eyes nails Dark Bites lips brittle new clothes Red Accepts Red fingers frayed Cuddly toes pitted coordinated Red Physically toes soft Webbed Nails Happy ears pale to care for Red Skin Pleasant/easy jointed birth mark(s) Double Dark Sensitive/affectionate arched palate bruising to be liked High Easy nodes enlarged neck to tan Lymph Inability Responsible warm birth mark(s) accurate pictures Head sweats cuticles to peoples’ feelings Head Ragged Sensitive sweats finger nails if parents leave Thickening OK fatigue toenails parent Abnormal Thickening Answers to thrive instructions Failure Vitiligo Follows all over spots or lines in nails words well Cold White Pronounces and feet skin in general memory Cold Dry Unusual intolerance cracking musical pitch Cold Feet Perfect - very sweaty peeling with math Hands/feet Feet Good very hot/sweaty cracking with computer Head Hands Good sweats peeling with fine work Night Hands Good - odd odor legs dry throwing and catching Perspiration Lower Good SKIN lackluster climbing Skin Good skin in general desire to do things severe Itchy Strong Paleness, scalp / fingernails Itchy Swimming Fungus ear canals free of fear / toenails Itchy Bold, Fungus eyes to be held Itchy Likes Dandruff to be swaddled nose skin Likes Chicken roof of mouth skin Itchy Oily arms dullness Itchy Patchy SLEEP hands on face Itchy Seborrhea in own bed Sleeps legs calluses Itchy with parent(s) Sleeps feet foot Itchy Athletes screaming/crying Awakens anus - stinky Itchy Feet at Awakes penis rash Itchy Diaper falling asleep Difficulty vagina body odor Itchy Odd waking Early body odor Strong Insomnia Acne DIGESTIVE less than normal Sleeps circle under eyes Dark bad sleepiness Breath Daytime get red Ears salivation during sleep Increased Jerks Eczema Drooling Nightmares Flushing lip corners more than normal Cracking Sleeps face Red on lips, face Cold to insect bites Sensitive tongue (map-like) Geographic PHYSICAL Stretch tongue Sore sick skin Looks Blotchy coated Tongue look Glazed love to bite you Bugs in mouth Canker cap Overweight Cradle bleed Gums Hair Underweight Dry grinding Teeth unusually large Scalp Pupils Dry cavities long eye lashes Unmanageable Unusual Hair with amalgam fillings Tooth unusually small Pupils
SYMPTOM REVIEW Please check all current symptoms occurring or present in the past 6 months. STRENGTHS Accepts new clothes Cuddly Physically coordinated Happy Pleasant/easy to care for Sensitive/affectionate to be liked Responsible accurate pictures Sensitive to peoples’ feelings OK if parents leave Answers parent Follows instructions Pronounces words well Unusual memory Perfect musical pitch Good with math Good with computer Good with fine work Good throwing and catching Good climbing Strong desire to do things Swimming Bold, free of fear Likes to be held Likes to be swaddled SLEEP Sleeps in own bed Sleeps with parent(s) Awakens screaming/crying Awakes at Difficulty falling asleep Early waking Insomnia Sleeps less than normal Daytime sleepiness Jerks during sleep Nightmares Sleeps more than normal PHYSICAL Looks sick Glazed look Overweight Underweight Pupils unusually large Unusual long eye lashes Pupils unusually small Dark circles under eyes Red lips Red fingers Red toes Webbed toes Red ears Double jointed High arched palate Lymph nodes enlarged neck Head warm Head sweats sweats Abnormal fatigue Failure to thrive Cold all over Cold and feet Cold intolerance Hands/feet - very sweaty Head very hot/sweaty Night sweats Perspiration - odd odor SKIN Paleness, severe Fungus / fingernails Fungus / toenails Dandruff Chicken skin Oily skin Patchy dullness Seborrhea on face calluses Athletes foot Feet - stinky Diaper rash Odd body odor Strong body odor Acne Dark circle under eyes Ears get red Eczema Flushing Red face Sensitive to insect bites Stretch Blotchy skin Bugs love to bite you Cradle cap Dry Hair Dry Scalp Hair Unmanageable Bites nails brittle frayed pitted Nails soft Skin pale Dark birth mark(s) Easy bruising Inability to tan birth mark(s) Ragged cuticles Thickening finger nails Thickening toenails Vitiligo White spots or lines in nails Dry skin in general Feet cracking Feet peeling Hands cracking Hands peeling Lower legs dry Skin lackluster Itchy skin in general Itchy scalp Itchy ear canals Itchy eyes nose Itchy roof of mouth Itchy arms Itchy hands Itchy legs Itchy feet Itchy anus Itchy penis Itchy vagina DIGESTIVE Breath bad Increased salivation Drooling Cracking lip corners Cold on lips, face Geographic tongue (map-like) Sore tongue Tongue coated Canker in mouth Gums bleed Teeth grinding cavities Tooth with amalgam fillings
Consult-intake-form.pdf.docx