Infant & Child Health History Form Page 2
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#2 Physical Stresses:
List all significant injuries and traumas:
List all hospital visits and approximate dates:
#3 Chemical Stresses:
List any current prescriptions or over-the-counter medications:
List any supplements (vitamins / minerals / herbs etc.):
Is your child exposed to second hand smoke on a regular basis (circle)? No Yes
Has your child been vaccinated (circle)? No Yes If yes, please list the vaccinations and any side effects:
______________________________________________________________________________________________________
How is / was the child fed as an infant (circle)? Breast fed (until the age of: _________) Formula fed
How would you rate your child’s diet (circle)? Excellent Good Poor
If breast fed, does / did the child have a side of preference (circle)? No Left Right
#4 Mental/Emotional Stresses:
Psychological stress has been shown to negatively affect the function of the nervous system. On a scale of 1
to 10 please rank your child’s overall mental / emotional stress level (1 = minimal to 10 = extreme):
/ 10
#5 General Health History:
Weight at birth: _________ Current Weight: _________Length at birth: _________Current Length/Height: _________
APGAR Score: ____/10 Reason(s) for loss of points: ________________________________________________________
Pregnancy:
Length: _________ weeks __________ days
Weight gain during pregnancy: _____ lbs
Medications / Drugs taken during pregnancy: ________________________________________________________________
Vitamin / Supplements taken during pregnancy: ______________________________________________________________
Was ultrasound performed? Yes No If yes, list the number and reason(s): ______________________________________
Was amniocentesis performed? Yes No If yes, list the reason(s) and result(s): ____________________________________
Illnesses during pregnancy (circle all that apply):
Elevated blood pressure
Toxicity
Gestational diabetes
Infections
Bleeding
Other: ___________________________
Labour & Delivery:
Length of hard labour: ___________ hours
Medical Intervention (circle all that apply):
Chemically induced labour
Epidural or other anesthetic
Caesarian Section
Forceps
Vacuum extraction
Other: ___________________________
Postnatal:
Number of wet diapers per day? _______
Number of soiled diapers per day? _______
When did the following milestones occur, if applicable?
Lifts head:
_____________
Sits independently:
_____________
Smiles:
_____________
Crawls:
_____________
Rolls over:
_____________
Stands independently:
_____________
Reaches for objects:
_____________
Walks:
_____________
Imitates sounds:
_____________
Talks:
_____________
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