Thank you for taking time to fill out this questionnaire. It is extensive, but history plays a vital role in functional health care so that your time and accuracy in filling out this document will allow us to best serve your child, you and your family. As well, the more detail that is on the form prior to your visit, the more time we will have to review the problems and their potential solutions. Dates of occurrence/onset are very useful to understand the problem please include them in any area which are appropriate.

If your child is old enough, please ask them to participate in filling out the form, particularly the REVIEW OF SYMPTOMS.  For areas that do not apply, please put “N/A” rather than leave them blank. If there is something that you do not know or are unclear about, please contact our office for clarification.