Belleville_Pediatric

Date of Initial Appointment

MonthDayYear
Who referred you to BIHC
Reasons for Visit
Confidential Client Information
Name
Address
CITY
PROVINCE
POSTAL CODE
(H) Phone #
(W) Phone #
(C) Phone #
Email
example@example.com
Age
Date of Birth

MonthDayYear
Pronouns

She/Her/HersHe/Him/HisThey/Them/TheirsOther
Preferred Method of Contact (Select one)

PhoneTextEmail
I agree to receive future email communications from B.I.H.C. containing news, updates and promotions. You may withdraw your consent at any time.

YESNO
Family Physician
Physician's Phone Number
Emergency Contact Name
Emergency Contact relationship to you

SPOUSEFRIEND/FAMILY MEMBER
Emergency Contact Phone #
Medications

List any and all medications/supplements you are currently taking.
Medication Name #1
Dosage/Frequency #1
Condition it Treats #1
Medication Name #2
Dosage/Frequency #2
Condition it Treats #2
Medication Name #3
Dosage/Frequency #3
Condition it Treats #3
Medication Name #4
Dosage/Frequency #4
Condition it Treats #4
Medication Name #5
Dosage/Frequency #5
Condition it Treats #5
Medication Name #6
Dosage/Frequency #6
Condition it Treats #6
Client History

Please answer all that apply:
Was your child full term (39 weeks+)? If not, please indicate how many weeks they were born at:
Select one:

Vaginal DeliveryC-section
Any complications with birth? (Vacuum, forceps, shoulder dystocia, etc) If yes, what?
Does your child have a preference to turn their head in one direction? If so, what side do they turn their head to?
Is your child breastfed, bottle fed or both? Please elaborate and include bottle type:
Has your child had a procedure to correct a tongue and/or lip tie? If so, when did this occur and who did the procedure?
Did/Does your child use a pacifier or suck their thumb/fingers?
Do you have any concerns about your child’s development? If so, please elaborate:
Does your child suffer from chronic ear infections? If so, please elaborate:
Does your child surfer from allergies? If so, please list:
Do you have any concerns about your child hitting their developmental milestones?
Do you have a family history of scoliosis or hip dysplasia?
Has your child experienced any of the following? Check/Circle and elaborate as needed:

Shallow latch at breast/bottleSlides/pops on and off the nippleFalls asleep while eatingColic symptoms/cries a lotReflux symptomsSpits up oftenGagging, choking, coughing when eatingGassyFussyPoor weight gainHiccupsLip curls under when nursing or taking bottleGumming or chewing on nipple when nursingPacifier falls out easily/doesn’t like itMilk dribbles out of mouth when feedingShort sleeping requiring feeds every 1-2 hoursSnoring, noisy breathing or mouth breathingFeels like a full time job to just feed the babyNose congested oftenBaby is frustrated at the breast/bottleHow long does it take baby to eat?How often does your baby eat?
How long does it take baby to eat?
How often does your baby eat?
Do you have any of the following symptoms? (If applicable) Please check/circle and elaborate as needed:

Creased, flattened or blanched nipples when baby is done a feed (or during)Lipstick shaped nipplesBlistered or cut nipplesBleeding nipplesNipple pain when baby first latches on (rate on scale of 1 to 10)Poor or incomplete breast drainageInfected nipple/breast (mastitis history or clogged ducts?)Using a nipple shieldBaby prefers feeding on one breast over the other? Yes or No. If so, which side?
Nipple pain when baby first latches on (rate on scale of 1 to 10)
Baby prefers feeding on one breast over the other? If so, WHICH SIDE?
Health History
Present involvement in other health care (Select all that apply)

ChiropracticAcupuncturePhysiotherapyMassageNaturopathicChiropody/PodiatryOccupational TherapyPsychology/PsychiatryOther
Have you received any medical and/or drug treatment for this complaint?

YESNO
Please provide details:
Surgery #1
Date #1

MonthDayYear
Surgery #2
Date #2

MonthDayYear
Have you had any of the following tests for the condition(s) for which you are presently referred?

X-raysUltrasoundCT ScanMRIBone ScanEMGBlood TestOther
Please check all health conditions that apply:

AllergiesAnemiaAppendicitisArtificial JointsAsthmaBleeding DisordersBowel/Bladder ChangesBrain/Head InjuryBronchitisCancerCataractsChemical DependencyConcussionsCongestive Heart FailureConstipationDepression/AnxietyDiabetesDiarrheaDeep Vein ThrombosisEating DisorderEmphysemaEpilepsyFaintingFibromyalgiaFrequent ColdsGastrointestinal issuesGlaucomaGoutHeadaches/MigrainesHeart AttackHeart DiseaseHepatitisHerniaHigh Blood PressureHigh CholesterolHIV/AIDSIrritable Bowel SyndromeInternal Pins/PlatesKidney DiseaseLiver DiseaseLoss of SensationLow Blood PressureMenopauseMultiple SclerosisNausea or VomitingOsteoporosisOsteoarthritisPacemakerParkinson’s DiseasePneumoniaPregnantRheumatoid ArthritisRinging in earsShortness of BreathSkin ConditionsSinus ProblemsStroke/TIASurgeryThyroid DisorderTMJ DysfunctionTuberculosisUlcersVaricose VeinsVertigoVision ProblemsOther
List of allergies (if applicable):
Type of Diabetes (if applicable):
Weeks pregnant (if applicable):
Should be Empty:

Confidential Client Information

Medications

Client History

Health History