Child New Patient Information Form

New Patient Information Form		carlstonmd.com

Child New Patient Information Form


Name________________________________________________ Birthdate__________________
Mailing Address______________________________City ____________________ Zip ________
UPS Address________________________________ City ____________________ Zip ________
Home Phone___________________ Parent's Work Phone ____________________
E-mail address______________________________________
IN THE EVENT OF EMERGENCY PLEASE NOTIFY:
Name ___________________________________ Phone ____________________________
Referred by? _________________________________________________
Prior Homeopathic treatment ?_____ By Whom___________________Date Last Seen _________
MEMBERS OF YOUR HOUSEHOLD

NAME

AGE

RELATIONSHIP

WHO SPENDS THE MOST TIME WITH THE CHILD ? ___________________________________________

OCCUPATIONS OF THE PARENTS/GUARDIAN ? ___________________________________________

ALLERGIES (please list all known or suspected drug sensitivities as well as environmental allergies)

__________________________________________________________________________________________

MEDICATIONS AND VITAMINS (include non-prescription)
NAME	DOSAGE	FREQUENCY

__________________________________________________________________________________________

HEALTH HABITS

Have you made your home as safe for your child as possible ?
(Consideration only, no answer needed)

Do you believe your child gets enough exercise ? __________

Does anyone smoke in the home ? __________

Does your child always wear seatbelts riding in an automobile ? __________

Does your child watch television or videos ? _______ How many hours each week ? _______

IS YOUR CHILD EXPOSED TO ANY TOXIC SUBSTANCES ?

(Please provide details regarding those exposures that concern you)

__________________________________________________________________________________________

WHAT HEALTH PROBLEMS ARE YOU PARTICULARLY CONCERNED ABOUT ?

__________________________________________________________________________________________

WHAT RECENT LOSSES OR UNUSUAL STRESSES HAS THE CHILD EXPERIENCED ?

__________________________________________________________________________________________

PLEASE CIRCLE ANY DISEASES THAT HAVE OCCURED IN EITHER FAMILY.
Alcohol/Drug Problems	Allergies	Alzheimers Disease	Anemia	Arthritis/Gout	Asthma
Bleeding Problems	Cancer	Convulsions/Epilepsy	Diabetes	Eczema	Emphysema
Heart Trouble	Hepatitis	High Blood Pressure	Kidney or Bladder Problems
Mental Illness	Migraines	Pneumonia	Polio	Rheumatic Fever
Stomach /Intestinal Disease	Stroke	Thyroid Problems	Tuberculosis	Ulcers	Venereal Disease
Weight Problems

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