Osteopathic Consultation Form

Child’s Name

Parent/Guardian Names

Age

Height

Weight

Pediatrician

CURRENT STATUS

Primary Problems

What would you like to have evaluated and treated today?

If it applies, please draw in the pictures below where this has bothered you or your child

When did this concern start?

What caused it to start?

What else was happening in your family around this time?

Other information you’d like to share about this

Does anything worry you about this concern?

What helps it feel better?

What makes it feel worse?

What helps you feel the best/happiest?

What triggers you to feel your worst?

Have you had these symptoms before?

Yes No

If yes, when? What happened?

Have you seen other care providers for this?

Yes No

Who?

When?

What was done?

Did it help?

What are your treatment goals?

TRAUMA ( Please give details and approximate dates)

NONE

1. Head trauma/concussion

2. Motor vehicle accidents

3. Injuries (sports, falls, etc.)

4. Dental work (extractions, braces)

5. Emotional trauma

6. Other

REVIEW OF SYSTEMS: Please check all that apply

NONE

General

Weight gain or loss, change in appetite/thirst

Fatigue, weakness,

Change in sleep pattern

Fever, chills, night sweats, cold intolerance

Change in quality of hair/skin, easy bruising

Irritability or indifference

Head, eyes, ears, nose and throat

Eye pain/disease, visual problems

Ear pain/infections/ringing, hearing problems

Chronic sinusitis, nasal discharge

Sore throat, change in voice

Difficulty swallowing

Skin

Itching, burning, rashes

(psoriasis, eczema, etc)

Lumps, tumors, cancer

Changes in moles/warts/lesions

Cardiovascular

Chest pain

Palpitations, arrhythmia, heart murmurs

Blood vessel disease, clots, thrombophlebitis

Foot/Ankle swelling

High blood pressure

Respiratory

Wheeze, asthma, use of inhalers

Shortness of breath – with activity/at rest

Frequent cough, bronchitis

Pneumonia, flu

RSV

Gastrointestinal

Nausea/Vomiting

Heartburn, reflux, hiatal hernia

Abdominal pain, ulcer

Change in bowel habits: diarrhea, constipation

Dark tarry stools, blood in stools

Irritable bowel synd., excessive gas, food intol.

Inflammatory Bowl Disease: Crohn’s, Ulc. Colitis

Urinary

Kidney stones, tumors

Frequent UTI, pain w/urinating

Bedwetting

Sexually transmitted diseases

Nervous System

Seizures, tremors

Headache, head injury

Numbness, tingling

Loss of coordination

Dizziness/Vertigo

Poor memory or concentration

Fainting

Change in taste, smell

Neurologic disease

Musculoskeletal system

Joint pain, redness, swelling, stiffness

Frequent/severe muscle pain/weakness

Disc herniation

Short leg syndrome

Abnormal curvature of the spine

Psychological

Often nervous/worried

Post traumatic stress

Often feeling sad or hopeless

Hospitalized for mental illness

Psych. diagnosis

(i.e., OCD, Manic Depression)

FEMALE Endocrine/Reproductive

Menstrual irregularity: flow, bloating, PMS

Decreased sense of well-being, decreased energy

Decreased mental sharpness/indecisiveness

Delayed or precocious puberty

MALE Endocrine/Reproductive

Decreased sense of well-being, decreased energy

Decreased mental sharpness/indecisiveness

Loss of muscle mass, strength

Delayed or precocious puberty

Is there anything else you wish to share?

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