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New Pediatric Patient Questionnaire (Ages 0-2)

Step 1 of 5 - Personal Information

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Parent / Guardian Information
Name of Parent or Guardian*
First Last
Email*
Email Communication*
- I consent to receive electronic communication messages from Back to Health & Wellness Centre.
- I do not consent to receive electronic communication messages from Back to Health & Wellness Centre
Phone# - Home or Cell*
Phone# - Work
Address*
Street Address City Province Postal Code
Referred by*
Please provide the name of who you were referred to us by, if applicable.
Child Information
Name of Child*
First Last
Address
- Address is different than Parent / Guardian
Child's Address*
Street Address City Province Postal Code
Sex*
Gender*
How did you find out about our clinic?*
Date of Birth*

During pregnancy, were you on any medication?*
- Yes
- No
What medications were you taking during pregnancy?*
Did you smoke during pregnancy?*
- Yes
- No
Did you have back pain during pregnancy?*
- Yes
- No
Were you physically ill during pregnancy? (Colds, flu, allergies, German measles, etc.)*
- Yes
- No
Please list any physical illness you endured.*

Approximately, how long was labour?*

: HH

MM
Was labour chemically induced?*
- Yes
- No
Was labour Doctor assisted?*
- Yes
- No
Was a C-section performed?*
- Yes
- No
Were forceps used?*
- Yes
- No
Did the doctor have his hands on the infant?*
- Yes
- No
How severe was your pain/discomfort during labour and delivery?*
- Low
- Medium
- High
Were there any complications before or during delivery?*
- Yes
- No
Please explain any complications.*
Was the baby premature?*
- Yes
- No
What was his/her age at birth?*
What was his/her weight at birth?*

Has your child suffered any of the following health problem?*
- Headaches
- Allergies
- Ear problems
- Sleeping disorders
- Breathing Problems
- Fatigue
- Irritability
- Hyperactivity
- Frequent Colds
- Flu
- Bloody Noses
- Meningitis
- Diarrhea
- Constipation
- Colic
- Rashes
- Milk/Lactose Intolerance
- Bed Wetting
- Digestive Problems
- Other
Please select all that apply.
Please describe any ''other" health problems.*
Is your child accident-prone?*
- Yes
- No
Please describe your child's tendency to be accident prone.*
Has the child had any falls down steps?*
- Yes
- No
Please describe the fall(s).*
Has your child ever fallen from heights?*
- Yes
- No
Please describe any fall(s) from heights.*
Has your child been involved in a motor vehicle accident?*
- Yes
- No
Please describe the motor vehicle accident(s).*
Has your child ever been hospitalized or had surgery?*
- Yes
- No
Please describe any hospitalization or surgery.*
Does your child suffer from allergies/sensitivities (environmental, foods, drugs, etc.)?*
- Yes
- No
Please describe any food allergies/sensitivities.*
Has your child received all childhood vaccinations?*
- Yes
- No
Does your child get regular flu vaccinations?*
- Yes
- No
If there have been complications from any vaccinations, please describe.*
Date of last Annual Physical Exam/Blood Test*
Date of last Antibiotic Use*
Reason for last Antibiotic Use*

Diet
Does your child eat or come in contact with any of the following?*
- Aluminum pans
- Plastic tupperware
- Microwave
- Air fresheners
- Scented body products
- Fried foods
- Fast foods
- Refined/processed food
- Candy
- Artificial sweeteners
- Luncheon meats
- Margarine
Does your child have any dietary restrictions? (Vegetarian, religious, etc.)*
- Yes
- No
What dietary restrictions do they have?*
On average, how does your child eat their meals?*
- With family around the table
- In front of the TV
- On the run
- Restaurant
- Fast food
Check all that apply.
How often does your child eat at a restaurant?*
- never
- rarely
- sometimes
- often
- always
How often does your child eat fast food?*
- never
- rarely
- sometimes
- often
- always
Please describe what your child typically eat in one day:
Breakfast*
Lunch*
Dinner*
Snacks*
Food Likes and Cravings*
Water (cups per day)*
Milk (cups per day)*
Lifestyle
How many hours does your child sleep daily?*
Does your child have problems sleeping?*
- Yes
- No
Does your child wake feeling rested?*
- Yes
- No
- Sometimes
Does your child have a bowel movement daily?*
- Yes
- No
Does your child suffer from headaches?*
- Yes
- No
If your child suffers from headaches. Please describe.*
Has your child ever had any broken bones or had sprain injuries?*
- Yes
- No
Please describe any breaks or sprain injuries.*
Is your child on any medication?*
- Yes
- No
Please list type of medication and dosage.*
Has your child had a scoliosis examination by an approved scoliosis determination clinic?*
- Yes
- No
Please provide details about the scoliosis examination.*
Is your child hyperactive?*
- Yes
- No
Please describe the hyperactivity.*
Does your child have a learning disorder?*
- Yes
- No
Please provide details about their learning disorder.*
Does your child have poor posture?*
- Yes
- No
Please provide details on their poor posture.*
Does your child have any problems associating with friends?*
- Yes
- No
Please explain any problems associating with friends.*
Is your child nervous or has anyone suggested that your child was nervous?*
- Yes
- No
If your child displays nervous behaviour, please explain.*
Does your child have asthma?*
- Yes
- No
Please provide details about their asthma.*
If you could improve one aspect of your child’s health or behaviour, what would it be?*

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Ottawa,
ON
K2P 2G8

(613) 237-3306

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