Atlas Forms

SYMPTOMS AND ILL HEALTH (PRESENT STATE OF ILL HEALTH)

Years of uncorrected injury or damage show up as acute or chronic symptoms or health problems.

Main purpose for this appointment:

Have you tried anything to ease this problem?

If you don't get this problem corrected, do you think it will get worse in the next 5 - 10 years?YesNo

On a scale of 1 to 10 (10 being the highest), what is your commitment to getting this problem corrected and improving your child’s health? (Circle)

Birth - 4 YearsFall from change tablefall down stairsinvolved in car accidentfall from playground equipmentplay in a 'Jolly Jumper'frequent ear infectionsfrequent crying spellsfrequent feversfrequent bouts of diarrheaconstipationcolicsleeping problemsfrequent colds

5 - 12 Yearsfall from treefall off bicyclefall from playground equipmenthyperactivitysports accidentinvolved in car accidentinjury from siblingsstomach painlearning disabilityallergies/ hay feverasthma

Vaccinationstetanuspoliomeaslesmumpsrubellapertussishepatitis Bdiphtheriahaemophilus Influenzae type brotaviruspneumococcal diseasevaricellameningococcal diseaseinfluenzahuman papillomavirus

Reactions to vaccinations?

Has your child experienced any of the following?headachesdizzinesstinnitusearachesallergies/ hay feverasthmafrequent coldsfatiguesleeping difficultiesmood changes'growing pains'excessive gas/ bloatingstomachacheswalking problemstingling or numbnesspainspinal curvaturejaw problemsfevernervousness/ depressionanxiety / fear

Which of the problems that you’ve checked off are you most concerned about?

Is there anything else you feel we should know?

By signing here, I verify that the above information is true and accurate regarding my child’s health history.

Today's Date: 25 Apr 2024

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