Prefered Physician:
Dr. Julie Buckley, MD
Prefered Visit Location:
Ponte Vedra (Jacksonville), FL
Cumming (Atlanta), GA (limited availability)
Patient Name:
Mother's Name:
Father's Name:
Patient Date of Birth:
Gender:
Street Address:
City:
State:
Country (If other than USA):
Zip/Postal Code:
Home Phone (Area code first):
Mother's Cell Phone (Area code first):
Father's Cell Phone (Area code first):
Mother's Work Phone (Area code first):
Father's Work Phone (Area code first):
Preferred Fax:
Preferred Email:
Patient's Primary Care Physician:
Primary Care Physician's Address/Phone/Fax:
Preferred Local Pharmacy Name/Phone/Fax:
Do you have a preferred local compounding pharmacy? If so provide Name/Phone/Fax:
Any known alergies to medications? If yes, please list and describe adverse reaction.
Privacy Constraints:
No Contstraints-OK to leave messages, send mail and e-mail
Restrictions-person to person communication with patient/guardian
only
Other
Emergency Contact Name:
Relationship to Patient:
Address:
Phone:
Insurance Information (while we do
not participate in any insurance "networks" and fees are due in full
at the time of your visit, our electronic medical record is able to
create a universal claim form for you to file if you wish):
Policy Holder's Name:
Policy Holder's Date of Birth:
Policy Holder's Relationship to Patient:
Insurance Company's Name:
Claims Address (on back of card):
ID Number:
Group Number:
Employer Name as Listed on Policy:
In the sections that follow, we are trying to familiarize ourselves with your child. Please be as descriptive as possible.
Pregnancy and Delivery
Anything unusual about the pregnancy? (Illnesses, medications,
antibiotics, difficulty):
Mother's Blood Type:
Child's Blood Type, if known:
Miscarriages?
Labor and Delivery Duration:
Delivery Method:
Vaginal
Induced
C-Section
Group B Strep:
Antibiotics at Delivery?
Anthing unusual about the delivery?
APGAR Score if remembered:
Anything unusual about the baby's hospital stay or initial
newbord period?
Infancy
Breast feeding (describe the length and character of feeding
effort):
Colic or milk intolerance (describe symptoms if present):
Formula used:
When was food introduced?
Medical History
Frequency of and age at first ear infections:
Asthma or allergies? If yes please describe:
Accidents or trauma? If yes please describe:
Hospitalizations/Surgeries? If yes list dates as well
as illness/procedures:
Diagnostic tests that have been performed on your child:
Specialist your child has seen and their impressions:
Right or left handed?
Development
Age at which you suspected something was unusual? Please describe what you felt was different:
Age at which your child rolled over:
Age at which your child sat up:
Age at which your child walked:
Words your child said at the time of their first birthday:
Did your child ever lose spoken words? If so please describe
the speach regression:
Did your child lose social and/or motor skills? If so
please describe:
Did you associate any regression with a vaccine? If so
please describe:
Current Status
Major food cravings:
List all foods your child consumes:
Does your child eat or mouth non food items? If so please
describe:
Potty trained? If yes, at what age?
Describe your childs stools-color, smell, consistency
(liquid, mashed potatoes, rocks, etc.) shape, (balls, snakes, etc.) frequency,
blood, mucus or whole food present, sink/float:
Does your child have bloating/pass excessive gas/unusual
belching/stomach ache/unusual behaviors associated with bowel movements?
Does your child cover their ears or show auditory defensive
behavior?
How does your child handle crowded places?
Does your child like certain kinds of touch and/or dislike
others? Describe:
Does your child have sensitivity to food textures or difficulty
swallowing?
Is cutting hair, nail cutting or brushing teeth difficult?
Does your child have sensitivity to texture of certain
clothing or tags?
Does your child have any OCD (obsessive/compulsive) type
behaviors (lining things up, rigid rituals, "stuck" on an object)?
Does your child have difficulty with transition from one activity or setting to another? Please describe:
Does your child have any stimming/repetitive behaviors
(toe walking, hand flapping, spinning themselves or objects, etc.)?
How does your child interact with children who are the
same age as they are?
How does your child interact with children who are older
or younger than they are?
How does your child interact with adults?
Does your child head bang/nail bite/self-mutilate/bite their arms or hands/skin pick? If so, describe:
Is your child moody/irritable/ difficulty focusing/ impulsive/
overactive/ anxious/fearful/ aggressive? Please describe:
Does your child have processing problems (auditory, visual,
motor, etc.)?
Does your child have fine motor difficulties, difficulty
with buttons/zippers, clumsiness, and/or gross motor skill troubles, etc.?
Does your child have language and/or signs? Describe:
Describe sleep from birth to present- briefly. Currently
how long to fall asleep, do they stay asleep, awakening time, naps:
With what daily activities do you have to help your child?
(Dressing, bathing, brushing teeth, eating):
What therapies is your child involved with currently?
What therapies have you tried in the past?
What type of school/educational program is your child
enrolled in currently?
What medications and nutritional supplements is your child
taking currently? (list name, dose, and frequency):
What medications and nutritional supplements have helped
the most?
What medications and supplements have a negative effect?
What aspects of your child’s current status concern
you most?
What are your goals for your child’s medical care?
List them in order of importance:
Is there anything else we should know about your child
or your family?
Review of Systems- if present, please indicate
if not described above
Breath holding, seizures, headache:
Fatigue/flushing/ dark circles under eyes/weakness/stiffness:
Cold hands/feet, cold/heat intolerance/ tingling of hands
or feet/ cracking or peeling of hands or feet:
Recurrent/chronic fever, recurrent illness/infection:
Blinking/ tics/ ringing in ears:
Bad breath/ nose bleeds/swollen gums/ dry lips or mouth:
Acute sense of smell/ hearing:
Night blindness in child/family:
Geographic tongue:
Dermatographism (you can “write” on their
skin with your fingernail and leave a transient red mark):
Hoarseness/ sore throats:
Grinding teeth:
Anal itching or itchy skin or itchy scalp:
Eczema/ psoriasis/hives/acne/seborrhea (cradle cap)/ sensitivity
to bug bites/ other rashes:
Easy bruising/ dry skin/ pale skin/ oily skin:
Thickening of nails, ridging or splitting of nails, brittle
or soft nails:
Strategies to put pressure on abdomen, reflux, colic:
Does your child lean on people or objects, do they lay down to play?:
Family History
In this section, we are looking for
genetic tendencies. If your child is adopted, please complete to the
best of your knowledge, information about the biologic parents. Please
consider, for each person, the following: asthma, allergies, diabetes,
blood pressure problems, strokes or heart attacks when young (40’s
and 50’s), blood clotting troubles (deep venous thromboses, pulmonary
emboli, abnormal menstrual cycles), kidney disease, seizures, migraines,
and other neurologic disorders, mental disorders (diagnosed, and “Uncle
Louie was a little nutty”, especially schizophrenia, bipolar
disease, depression, anxiety), substance use/abuse, hormone problems
(most commonly thyroid troubles), autoimmune diseases (Lupus, rheumatoid
arthritis, chronic fatigue, multiple sclerosis, etc.), night vision
disturbance, gut troubles (Celiac, Crohn’s, constipation, irritable
bowel, etc), learning disabilities, ADHD, etc:
Mother’s date of birth and medical history:
Father’s date of birth and medical history:
Siblings- names and dates of birth and medical history:
Maternal grandmother year of birth and medical history:
Maternal grandfather year of birth and medical history:
Paternal grandmother year of birth and medical history:
Paternal grandfather year of birth and medical history:
Any maternal siblings and significant medical history:
Any paternal siblings and significant medical history:
Any of your child’s cousins with significant medical
history:
Social History
Mother’s education:
Mother’s occupation:
Father’s education:
Father’s occupation:
Who lives in the house?
Who would your child call their family?
Who are your child’s caregivers?
Do you have family nearby?
What is your support system for treatment and care of
your child?
Do you have pets? If so, what kind, and how does your child do with them?
Does anyone smoke at home?
Environmental History
Location of home (city/suburban/wooded/farm/etc):
Water source for home (well/city/filtration system and
type if present):
Heating/Cooling system type (electric/gas/oil/other):
Do you live near power lines/woods/industrial area/water?
If you live near water, please describe (swamp, river,
ocean, retention pond, etc.):
Does your home, and especially your child’s room,
have a lot of dust/mold/feathers/stuffed animals? Please describe:
