Pediatric Medical Questionnaire - Forbes Nutritional Consulting

Our ability to draw effective conclusions about your child’s present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by the clinician during your consultations.

Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify underlying causes of illness and will also assist us to formulate a treatment plan.

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Name*
First Last
Your Child's Name*
First Last
Email*
Phone*
Age
Date
MM slash DD slash YYYY
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Birthdate*
Sex
- Male
- Female
Height
Weight
Occupation
Fees for Service: I ask that you pay-in-full at the time of service. I accept cash, personal checks made payable to Forbes Nutritional Consulting, and PayPal online. There is a $35.00 fee for all returned checks. If you wish to submit an invoice for reimbursment to your insurance company I can provide a record of our appointment for you to do this.
- Initial Consult
- Follow-Up Appointments
- Resting Metabolic Rate
- Other
Please specify other.
Main Reason for This Visit
Known Diagnoses or Health Problems
Health Goals
Current/Ongoing Problems
Describe Problem Mild/Moderate/Severe Treatment Approach Success
Do you have any pets or farm animals?
- Yes
- No
If yes, where do they live?
- Indoors
- Outdoors
- Both
Have you lived or traveled outside of the United States?
- Yes
- No
If so, where?
Has your child or anyone any family recently experienced any major life changes?
- Yes
- No
If yes, please comment…
Experienced any major losses in life?
- Yes
- No
If yes, please comment…
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Number of courses of antibiotics:
- Less than 5
- 5-10
- More than 10
How often have you taken oral steroids? (Cortisone, Prednisone, etc.)
- Less than 5
- 5-10
- More than 10
List all medications you are taking (including over the counter meds and birth control pills – past or current)
Click “+” to drop down more boxes
Name Date Started Dosage
Please list any allergies to medications.
Click “+” to drop down more boxes
List all vitamins, minerals, and other nutritional supplements that your child is taking now. indicate whether mg or IU and the form (e.g., calcium carbonate vs. calcium lactate)
Name Date Started Dosage
Childhood
Was your child a full term baby? Preemie? Breast Fed? Bottle Fed?
As a child, what foods were avoided because they gave you symptoms? Please describe (ex. milk- gas and diarrhea)
Food Symptom

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Last check-up	Cholesterol test	Blood test	Rectal exam	Stool blood test

Sigmoidoscopy	Mammogram	Pap smear	Bone density test

None	Bacon/Sausage	Bagel	Butter	Cereal	Coffee	Donut

Eggs	Fruit	Juice	Margarine	Milk	Oat Bran	Sugar

Sweet Roll	Sweetener	Tea	Toast	Water	Wheat Bran	Yogurt

Describe Problem	Mild/Moderate/Severe	Treatment Approach	Success

Candy	Cheese	Chocolate	Cups of Coffee w/ Caffeine	Cups of decaf coffee or tea

Cups of Hot Chocolate	Cups of tea w/ caffeine	Diet Sodas	ice cream	Salty foods

Slices of white bread/rolls/bagels	Soda w/ caffeine	Soda w/out caffeine

For how long?	Amount per day	Year Quit	Cigar	Cigarette	Smokeless	Pipe	Patch/Gum

Name	Date Started	Dosage

Name	Date Started	Dosage

Food	Symptom

Yes/No	Packs Per Day/Week

End of Section 1 – Please continue