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Teen history form Page 1 Teen histîry form: for young adults ages 12 through 18. Datå: Name: Age: Date of Birth: Cirñle: Male or Female Height: Weight: Names of Parånts/ Guardians: Address: City or town: Prîvince: Postal code: Home phone: PàrentÁs work phone: Email address: Name of persîn completing intake form: Medical Histîry: How did you find out about the naturopathic services at this clinic? Last physician or practitioner seen? Whån? Have you ever sought help from another Naturopathic practitionår? What is the main reason for coming today? How long have you eõperienced this? Is it getting better or worse over timå? List in order of importance other håalth concerns & length of time: Concårn How long has this lasted? Page 2 Which of the following have you eõperienced? And indicate ÁCÁ (current) or ÁPÁ (pàst) or ÁFÁ (frequent): Ear infections Eñzema/ Skin problems Digestive problems Growing pàins / Scoliosis Tonsilitis Allergies Colic Såizures Pneumonia Asthma Constipation/ Diarrhea Attentiîn Problems Á ADD/ADHD Sinus troubles Håadaches Nausea/ Vomiting Bed Wetting Chicken pox Mumps Roseolà Measles Bronchitis/ Upper Respiratory Infeñtions Other (please specify): Has you ever been hospitalizåd (other than at birth)? Date Reason Plåase list present and past medications, along with reason: Medicatiîn When? Reason? Approximate number of dosås of antibiotics you have taken: Please list any herbal or vitàmin supplements you take: Have you been vaccinated? Yes No If yes, whiñh ones? Were there any reactions obsårved? Please explain: Do you exercise? Yes No What type of eõercise? Page 3 Prenatal History: Were you pråmature? Yes, # weeks: No Ultrasounds during pregnanñy? Yes, number: No Medications during pregnàncy? Medications during labour/ delivery? Whàt type of delivery did you have? Any complications during dålivery? Location of birth: Hospital Birth cåntre Home ChildÁs weight at birth: ChildÁs height at birth: Were you breastfed? Yås, months. No Or formula fed? Yes; Type: . Introduced to sîlid foods at months. CowÁs milk at months. Fàmily History: Relative Living (age) Håalth problems Died (age) Cause Mothår Father Siblings (List): Grandmother (MîmÁs mom) Grandfather (MomÁs dad) Grandmother (DadÁs mom) Grandfathår (DadÁs dad) Other - specify (aunts, unñles, etc) List any known allergies: (Includå foods, medications, environmental, animals, etñ.) Page 4 Have you ever traveled abroad? Yes No Lîcation Age at time of travel School History: Current gràde: School contact: number: How many schools have you attånded? Have you ever dropped out of school? Average gradås: Specific learning disabilities: What have teàchers/ principals/ guidance counselors said about you? Do you enjîy school? Yes No Do you enjoy learning? Yes No Do you find school challånging? Yes No Do you participate in extra-curricular activities: Yes No Please list your hobbiås/ sports: What is your perceived stress låvel? (1 is not stressed, 10 is very stressed)